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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) { <br /> SEPTAGE � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District . <br /> rn Business Name (DBA) A2"0. P"g-rtmo - Address— 4P :,fo - - <br /> z Owner Address <br /> a <br /> 2 Firm Partners, Addresses and Telephone eNumbers <br /> aBusiness Telephone No. -0 ? -- - Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) _ Title d : Date A� t <br /> Please check Applicable Category(1-7) and Fill in the Re uired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) O <br /> For July 1', June 30, 19 - - Disposal Sites - <br /> Description(Make/Yr., Calor) <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, June 30, 19 <br /> No. of Vehicles Stored <br /> Flo. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time <br /> 4. 25 SANITATION PERMIT <br /> Job Address/Location _�3 ✓c� <br /> Alz <br /> Owner p w• /3IL'd A&"7%/ Address /72--F- <br /> ❑ SEPTIC TANK In CESSPOOL LEACHING FIELD W SEEPAGE PIT ❑ PACKAGE PLANT r <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ;91 REPAIR ❑ OTHER r tet+ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction `- Disposal Site <br /> 'No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -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: <br /> 9 SIZE: ❑ Less Than 1,000%, Ft., ❑ More Than 1,000 Sq. Ft: <br /> ❑ DRY 4rt�iuor�rs Used/AmounUMo. <br /> i����i�eTi��t��i���gpllt� ����g�� � f°`�a p-rtor�nanceoithe.vprkforwhiciithisperraitisissued,isilaiinotempt4yaliypBrsoq <br /> rrdtsq"f etrt:fvthatinthe <br /> �"�11ttMlttll'q hiHils7 ¢�� �}�.p�rag131 �"'t�'"'t��k)uti �j�gtlAatitc�nia." <br /> ' L'i1t)tig�r t;1Ci�i�ti5 Zt11)EC#t0 ivCfijc,natl&e[#tt�1}ilri�"vt1�������+���,�' �`.^t,G.Ying; "l certify tela#in the perforina,lce at-the work for which#leis permit is issued,i shall <br /> t _ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> r <br /> ordinances, state laws, and rules and r gulatio of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 &Received By January 31 ❑ Juty 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE- REMITTED - AMOUNT <br /> r <br /> FEE S" = <br /> y , <br /> LESS <br /> PRORATION <br /> PLUS ' <br /> PENALTY a ^• '� - - <br /> OTHER. <br /> OTHER <br /> Received by. pate Receipt No. Permit N . - I suance ate Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO:- 'ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />