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�. Applications Will Be Processed When Submitted Properly Completed. BeSureTosign ineAppllCauon. <br /> APPLICATION � - <br /> (For Non-Transterable,-Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic ion is hereby_ ade Eo ca on business' the ju i fictional area of th Sa Joaquin•Lo al Health District <br /> rn Business Name (DBA) <br /> z Owner L-- Address <br /> a a� r <br /> Firm Partners, Addresses an Te <br /> o. epho Number <br /> Emergency Telephone No.. <br /> + a Business Telephone No. <br /> a Contractor Licence No. is � � <br /> LApplicants Name (Print)i • a—ice` �' . r ate- <br /> Title . <br /> Please check Applicable Category (1-7) and Fill.in the Required Information <r r »r? - ,y�.•'. ''„ <br /> fr1 LJ" <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) - <br /> For July 1, ' June 30, 191, --=Disposal Sites ' } <br /> Descriptio.n,(Make/Y .., Coior)T - _ <br /> CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity I� Gal.,'Weights &Measures No. <br /> Equipment.Parking.Address <br /> 2. ❑ PUMPER YARD <br /> For J_ul 1, June 30, 19111 <br /> 'C i <br /> No. of Vehicles Stored <br /> No. of Chemical ToiletsJStored 11i I ) <br /> 3. ❑ PERCOLATION,TEST <br /> or <br /> R.S. _R.C.E.,NO. _ <br /> R.S. or R.C.E. Name 3 '�:_ - ' <br /> Test Location p y4�Test`Date Timed <br /> 4. ❑ SANITATION PE <br /> Addr Locatio �'' r <br /> Job <br /> wrier L u, Address } <br /> SEPTIC TANK¢ ❑ CESSPOOL LEACHING-FIELD ❑ SEEPAGE PIT C1_PACKAGE PLANT <br /> C1 PERMANENT i ❑ TEMP'ORARY NEW � ❑ REPAIR ' 11 OTHER <br /> 5. El CHEMICAL TOILETS For July 1, -June 30, 19 _ - ! • , i E , ,� <br /> Type Construction �MI .Disposal Site <br /> Ji No. of Units : al rage/CleaningLocation(s)E ui merit Sto <br /> 6. ❑ PACKAGE TREATMENTPLANT For July 1,-June 30;'19 <br /> = t t•,.T`-:- hlVtiere Certified �' ' <br /> Operator Name I ) <br /> Plant Location �1. ( ri y <br /> Plant Capacity No. Units Served l I <br /> 7. ❑.LAUNDRY�For July 1,: June 30, 19 <br /> SIZE,-"' 13 Less Than 1,000 Sq. Ft., ❑ More Than 1,000.Sq. Ft" w <br /> 1. , k <br /> ❑ DRY CLEANING, Chemicals:Used/Amount/Mo. : -- <br /> f'► i I <br /> I 'hereby certify I have prepared this application and that t e work I be done in accordance with San Joaquin County <br /> ordinanc laws, ules and regulahe Sa Joa i L c tri}c}t. <br /> tion o I <br /> II _ 1.- • <br /> APPLICANT'S SIGNATURE *. <br /> ! _ FOR DEPARTMENT USE ONLY <br /> By J <br /> Fee Is Due: ❑ ANNUALLY- __. ❑ PER UNIT [3PER SITE © EACH ❑ January 1 &Received By January 31 ❑ July 1 A Receiv RSMITuIy 31 <br /> li. BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION i DATE DAVE ^',�- .i EMITTED. - AMOUNT L_ <br /> #� <br /> lip -, <br /> FEE'wr....�...-�""'"`+'r... <br /> LESS <br /> �-PRORATION <br /> PLUS I W <br /> PENALTY y <br /> OTHER <br /> OTHER 11�i <br /> + ec ived byDate Receipt NO. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL.I;COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />