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rocessed When Submitted Properly Completed. <br /> Applications Will Be P <br /> I APPLICATION <br /> (For'Non-Transterab}e,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT -' <br />` LIQUID WASTE ; <br /> > 7� <br /> t <br /> Made to �n business in the jurisdictionalAadrderessthe S Joaquin <br /> Application isereby mLocal Health District <br /> I w Business Name (DBA) — Address f/GL <br /> aOwner Z �i <br /> Firm Partners, Addresses and Telephone ers , Emergency Telephone No. y <br /> I a Business Telephone No. <br /> Contractor Licence No. Title f l xl Hate <br /> LApplicants Name (Print) X., s <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR oEACH S VEHICLE) <br /> For July 1, June 30, 19 <br /> Description(Make/Yr., Color) CAL. License No. CAL. License Renewal No. <br /> 1 Serial No. <br /> Capacity Gal.,Weights & Measures No, <br /> Equipment Parking Address <br /> y ❑ PUMPER YARD e <br /> For July 1, June 30. 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT l7 ,4/�5 G <br /> k Job Address/Location f T H 4 <br /> �j T` Address ❑ PACKAGE PLANT <br /> Owner r -- IACHING FIELD ❑ SEEPAGE PIT <br /> SEPTIC TANK ❑'CESSPOOL: _ ._❑.OTHER <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW , T ❑ REPAIR - <br /> g. ❑ CHEMICAL TOILETS For July 1, -June,30; 19 <br /> Disposal Site <br /> Type Construction <br /> No. of Units EquipmentsStorage/Cleaning Location(s) P- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1; June 30, 19 Where Certified y <br /> Operator Name <br /> Plant Location- No. Units Served <br /> 1 Plant Capacity. <br /> 7, ❑ LAUNDRY For July 1, -June 30,19MOfe Than 1,000 Sq. Ft. <br /> SIZE: 13 Less Than 1,000 Sq. Ft., <br /> I ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> r <br /> k <br /> I hereby certify that I have prepared this apolnc o�the San hJoaquin Local Health District.ccordance with San Joaquin County <br /> I <br /> tio�p <br /> ordinances, state laws, and rules and re I <br /> APPLICANT'S SIGNATURE X I <br /> FOR DEPARTMENT USE ONLY' <br /> Fee IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1,&'Received By January 31 ❑ .luiy 1 &Received By July 31 <br /> REMIT <br /> a AMOUNT DUE CHECKED <br /> M) <br /> BILLING RE `F REMITTED AMOUNT <br /> C BASE EXPLANATION DATE -DATE <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> e OTHER <br /> ;J Delivered <br /> _ Receipt No. Permit No. <br /> Vssuance Date <br /> Mailed <br /> Received by Oate 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA-95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEAMITlSERYICES 'a' <br />