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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> APPLICATION <br /> - (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ' h reby a to carry on business in the jurisdictional area of the. t aquin Lal Hea�h istri . G � <br /> y Business lame (DBA) �� �.0� Addre� �U6ii <br /> L l <br /> aOwner r"`} ' r.rz' .. Address <br /> U Firm Partners, Addresses and T lephone Numbers ,y v + <br /> / -1461 Emergency Telephone No. 7�'7.L7- 533 <br /> ILBusiness Telephone No. �• a v f <br /> Contractor Licence No. - r <br /> a ELM <br /> O i�•SDt Title. i Date T /Y1At�LG6# t <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information.., s ,; <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I <br /> For July 1, . .-.June 30, 19 - Disposal Sites <br /> Description(Make/Yr.,Color) �— <br /> Serial No. CAL. License No.- CAL. License Renewal No. I <br /> Capacity Gal.,Weights & Measures No. I <br /> i <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July i, - June 30, 19 <br /> No. of Vehicles Stored { <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4, SANITATION PERM /, <br /> 7 ,N'16125�r+� t1� h 1 Q�-0wa Gl7�Sr `7q �6c. <br /> Job Address/Location Z <br /> Owner __ _ D �p Address <br /> ;. ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ P CKAGE PLANT <br /> U SEPTIC TANK_ ❑ CESSPOOL ,_,P c <br /> '❑'PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHERY�y .s� S'� �6 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Id�� <br /> Type Construction - Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) y . <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 .--Z <br /> f i Where Certified <br /> Operator Name <br /> Plant Location <br /> No- Units Served <br /> Plant Capacity 4 <br /> i' <br /> 7. ❑ LAUNDRY For July 1, -,June 30, 1.9 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this lication and that the work will be done in accordance with.San Joaquin County <br /> ordinances, state laws, ay rul and regu ion f the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July31 <br />. _ _ -- -- — REMIT <br /> EXPLANATION BILLING REMITTANCE $ AMOUNT1.`.-c CHECKED <br /> BASE <br /> _ DATE DATE REMITTED AMOUNT <br /> FEE e _ <br /> LESS �- <br /> PRORATION <br /> PLUS <br /> PENALTY <br />+ OTHER <br /> . _ ! -. <br /> OTHER "" -Ile <br /> i <br /> 313 11 aDeliv¢red <br /> Received by Date Receipt No. Permit No. Issuance Date - Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HATELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />