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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> u APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i reby made t carry an bu ess I the' risd' ionai area of the Sari.J aq Local Helalth District <br /> rn Business Name (DB i Address YF= ,� fY - <br /> aOwner Address �% -- <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. od p-5/�`S Emergency Telephone No, <br /> Contractor Licence No. <br /> Applicants Name (Print) Title / Date �� f <br /> Please check'Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER.VEHICLE PERMIT'REGISTRATION (FOR EACH VEHICLE) <br /> For July,1, June 30, 19 Disposal Sites <br /> Description'(Make/Yr., Color)V W, <br /> Serial No. CAL. License No. CAL. License Renewai No. <br /> Capacity Gal.,Weights & Measures No. ft i <br /> r <br /> Equipment Parking Address <br /> f 2. ❑ PUMPER YARD i <br /> For July 1, June 30, 19 <br /> I No. of Vehicles Stored N <br /> No. of Chemical Toilets Stored <br /> 4 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. -N } <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner - Address*o � <br /> ❑ SEPTIC TANK ❑ CESSPOOL r TOKLEACHING`FIELD' '❑ SEEPAGE PIT1 l❑(`PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY !❑"NEW""'^ ®REPAIR"""`❑'OTHER --�- <br /> 5. ❑ CHEMICAL TOILETS Fpr July 1, -June 30, 19 <br /> Type Construction Disposal Site # <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> I <br />� Plant Lavation I �P <br /> ---T <br /> Plant Capacity T <br /> Na. Units Served ` <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 t41 <br /> ❑ ❑ More Than 1,000 S p <br /> SIZE: Less Than 1,000 S Ft., q. Ft. ��� # <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> w I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules 99d regulations of a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ^� <br /> FOR DEPARTMENT USE <br /> Feels DUO: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH S ary 1 &Received By January 31 ❑ July 1'&Received By July 31 <br /> BILLING TANCE $ J REMIT <br /> f' BASE" ' EXPLANATION AMOUNT DUE CHECKED . <br /> DATE k D TE REMITTED AMOUNT- <br /> FEE S <br /> LESS <br /> 5 � PRORATION <br />€ PLUS <br /> + PENALTY <br /> OTHER <br /> r . OTHER r <br /> Received by Date -Receipt No. - Permit No. Is ante Date Mailed Delivered <br /> E. I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' J/fJ 1 1 AZELTQNi�,P.Q.�t f009 STOCKTON,'CA 45201' <br />