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Appllcatfons Will Be Processed When:Submitted Properly Completed. Be Sure To Sign The Application. <br /> -APPLICATION- <br /> (For Non-Transferable,Revocable;and Su spendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ye LIQUID WASTE } <br /> - Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> NBusiness Name (DBA) SGtI S'i -Address <br /> a Owner i, Address _,. . <br /> J Firm Partners,Addresses and Telephone Numbers ' + <br /> CL <br /> Business Telephone No. Emergency Telephone No., <br /> -Contractor Licence No. <br /> L Applicants Name (Print) A _ -Title DateZa-Z-ZI <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, 1916 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. Y CAL. License Renewal No. <br /> Capacity Gal-,"Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD-1 , <br /> For July 1, June 30, 19 µ :1 ta:lti s" .. •t <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 bate/Time <br /> 4. JX SANITATION PERMIT ��" <br /> Job Address/Location <br /> 6 <br /> Owner AddressyzCa <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ 'SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 1 REPAIR OTHER S!!/r`,- <br /> 5. ❑ CHEMICAL TOILETS For`July 1, -June 30, 19_ <br /> "Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location Oe, <br /> 6. 11PACKAGE TREATMENT PLANT For July 1, -June 30, 19 -rfy <br /> Operator Name iM 16 <br /> Where Certified <br /> Plant Location <br /> Plant Capacity �! .. +:No. Units Served �:� <br /> 7. 11 LAUNDRY For July 1, -June 30, 19' >< "' ""- t _ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ Mo_re Than 1,000 Sq. Ft. E' (� <br /> ❑ DRY CLEANING, Chemicals Used/.Amount/A6. <br /> rl <br /> I hereby certify that I have prepared this application and that t dWork will be done in accordance with San Joaquin County, <br /> ordinances, state laws, and rules and regulations of. -San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X t r t <br /> -� r�,' .�. �- ���- - ,+•. � moi. -}. ,�, �- - - �-+ �f k, - <br /> 9.11I1I FOR DEPARTMENT USE ONLY <br /> Fee IS Due., ❑ ANNUALLY I�❑ PER UNIT ❑ PER Sf7£' ❑ EACH" ❑ January 1 &Received Y_ed By Januar 31 ❑ July 1 Recewed By July 31 <br /> -- y & <br /> BILLING REMITTANCE , ; REMIT <br /> _ BASE I EXPLANATION $ �!+ <br /> - DATE•,. __4DATE _ REMITTED -W 'T AMOUrET DUE-� (, -CHEGKEDi <br /> AMOUNT <br /> FEE 7 0 <br /> LESS �`" ` • <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER II r <br /> OTHER <br /> Received by Date I� Receipt No. Permit No. Issbanci Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES 11 TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201T <br />