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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 /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application/is�hereb made carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) 1C/i Z, - f4RR4$'f1�r Sd�Cf Address <br /> aOwner Address x <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. '��d .' /.�4 Y_ Emergency Telephone No. } <br /> Contractor Licence No. ' <br /> LApplicants Name (Print) 0e2Fz/k(__ /15 R" g `rs L x Title Date <br /> Please check Applicable Category.(1-7) and Fill in the Required Information 4 ~� <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 /> For July 1, 4 June30.-.1.9:�.» ---°,,. ..--.- <br /> No, of Vehicles Stored <br /> Na. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST a <br /> 1 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> .Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT i <br /> Job Address/Location <br /> Owner egk s, /-SI4";c zf Address J� - <br /> . I> <br /> ❑ SEPTIC TANK; ❑ CESSPOOL .9 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> I 1J <br /> No. of Units Equipment Storage/Cleaning L'ocation(s)6 i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name f I' - .. Where Certified <br /> Plant Location <br /> Plant Capacity + No:.-Ur Afse'rved -� ! <br /> 7. ❑ LAUNDRY i For July 1,-June 30, 19 C�. <br /> -r <br /> SIZE: © Less Than 1,000 Sq'. Ft., ❑ More Than 1,000 Sq. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r <br /> `� �PAC i�af P� ��rdtfi.�sah�fall�vr �:7rP! it��h�li tt�� e �rr4a» �fihe��g l rf��e3s4hlspermil15J$300,1shallnotemployanyperson <br /> ! 1 Y ri iae�s r4f+)t�e115�il fl Was al.cagdan it ` I i <br /> !�* gf9e' hiriAcs �r 6Lb sorx�ractir�� sjpr:ature sert+ffes the fojiow�rs =f�T1ify lb3l itI l p£tllNTl3ans�Of i}�work f91 i/fliCb flats permit is issued,i Sh,71i <br /> I&ff, 9tYf§g ,5 s ?J51 I9�ykrtiap s Gg1i9l)Qf15�tI1g,1}1y1s g{G. itf�fia:'' <br /> I _ � <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, and rules and regulations of the San Joaqui ocal Health District. <br /> APPLICANT'S SIGNATURE <br /> _ FOR DEPARTMENT USE ONLY t <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1 BILLINGREMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> _ ...,, ,.,,.DATE _. DATE. y REMITTED AMOUNT <br /> FEE . - <br /> LESS -j <br /> PRORAT40N <br /> PLUS <br /> PENALTY tY-. <br /> OTHER <br /> - E- .Pe <br /> OTHER <br /> Received by Date Receipt No Per it No. I suance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES- '1601 E.HAZELTON AVE.,P.O.'Box 2009 STOCKTON,CA 95201 <br />