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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,'Revocable,and Suspendable) SEPTAGE <br /> f. ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Heal h Districti 1157 <br /> rn Business ame (DBA) Address` d ��126fUDr � <br /> a Owner— �_ !✓I SS INC_ Address f G _`kEsJ -Y r� -A <br /> Firm Partners, Addresses and Telephone Numbers 9100 � <br /> aBusiness Telephone No. . r Emergency Telephone No.. Z_2-- <br /> Contractor Licence No. /�� <br /> G Title �iC� f VIL to o <br /> Applicants Name (Print "� D <br /> Pjease check Applicable Category (1-7) and Fill in the Required Information �1 �{��� 5• fa.; L1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, ' June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> T­ <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of-Chemical Toilets Stored <br /> 3."0-PERCOLATION TEST t + est <br /> r G R.S. or R.C.E. No. Z <br /> R.S. or R.C.E. Name <br /> Test LocationI j LJ j,�� � 6F Test Date/Time 92 b Q ps, VVI <br /> 4. ❑ SANITATION PERMIT (n <br /> Job Address/Location `d) <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL_ ❑ LEACHING FIELD ❑ SEEPAGE PIT F❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR'` _ ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30,�19 � " R <br /> Type Construction . Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> B. ❑ PACKAGE TREATMENT PLANT For July 7, -June 30, 19 <br /> Operator Name - _ Where Certified„ <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 ' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑' More,Than 1,000 Sq. Ft. ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> SI <br /> 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, d rules and regulations of the San Joaquin-Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 17oN-rafu k <br /> FOR DEPARTMENT USF ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER U_NIT ;"v40'-PER SITE, .'s• ❑ EACH f❑:Jarivary 1&'Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> s BILLING RETTANGaE ..#'.. `' , AMOUNT DUE "'� +CHECKED <br /> BASE EXPLANATION PATE TE -.REMITTED' 1' <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION r tet <br /> PLUS <br /> PENALTY - <br /> OTHER . <br /> OTHER <br /> Received'byl Date Receipt No. I Permit No, Issuance Date Mailed Delivered <br /> APPLIC T—RETURN ALICCOPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES `1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> i <br />