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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> �. SEPTAGE <br /> - ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 017,ko k <br /> Application Is r b made to carry on business in the jurisdictional area of the San Joaquin cal Health District <br /> yu °� f fl i C Address �e <br /> HBusiness Name (DBA) h <br /> z Owner shv e, dis n, Address <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. <br /> �,'',�#�'{.�--01 Title 0L��1 A Date_ V <br /> LApplicants.Name (Print}_�_� <br /> Please check-Applicable Category (1-7)and Fill in the Required Information i <br /> 1: ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ; <br /> For July 1, June 30, 19 Disposal Sites - <br /> Description.(Make/Yr., Color)__.. — CAL.License Renewal No. <br /> Serial No CAL. License No. <br /> Capacity Gal., Weights & Measures No. . <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD-_ I <br /> For July,1, June 30, 19 <br /> r , No. of Vehicles Stored <br /> I No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST' <br /> R.S. or R`C.E.No. g <br /> r R.S. or R.C:E. Name.- <br /> ------- - ' .. - - s Z:r r <br /> t Test Date/Time } <br /> Test Location � <br /> 4. ❑ SANiTAI iON.PERMIT <br /> kJob Address/ ocation` 7 0 r "" <br /> Owner '1't-D fl Address � <br /> :SEPTIC TANK ❑ CESSPOOIL LEACHING FIELD, :X SEEPACpE.,PIT ❑ PACKAGE. <br /> �❑ NEW ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY T ❑ REPAI.FI <br /> k <br /> i 5. ;❑ CHEMICAL-TOILETS For,July 1,=June 30, 19 <br /> t Type Construction c` -Disposal Site <br /> r - Equipment Storage/Clean ng Lacation(s), <br /> No. of Units ^�= r .� Q <br /> 6. �❑ PACKAGCTREATMENT.PLANT For July 1, -June 30, 19. Where Certified } <br /> € Operator Name ! r rx d } TTkf <br /> _ �• ^' <br /> s Plant Locationt. <br /> LIPlant Capacity No. Units Served <br /> t7.• ❑ LAUNDRY For July 1, -June 30, 19' �, t <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑•,More Than Sq. Ft.- <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. ----l <br /> ( f I hereby certify that I have.pre 'red-this-application and that the work will be done in accordance with San Joaquin County <br /> i ordinances, state laws, and I and regul Tions e-San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> may. <br /> oy <br /> -FOR DEPARTMENT.USE ONLY <br /> - A <br /> Fi <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑-PER.�SITE QrEACH ❑ January 1 &Received By,January 31 ❑ July 1 R ReceivedEB+ylTuly 31 <br /> BILLING •REMITTANCE s $ _ AMOUNT DUE CHECKED <br /> f'SASE EXPLANATION DATE DATE: REMITTED f AMOUNT <br /> FEE x �,... ♦w � � � � � � �O � <br /> Y _A <br /> ` LESS r G U <br /> + i PRORATION <br /> 4 <br /> PLUSq <br /> PENALTY <br /> OTHER <br /> 4 OTHER +`• y �� <br /> _ <br /> Date, Receipt No. Permit No. I uanc Date d Delivered <br /> Received by - �'. ""' �Y - <br /> - -- 1601 E.HAZELTON.AVE.,P.D.Box 2009 STOCKTON;GA 95201 <br /> - APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH,PERMITlSERVICE5 <br />