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if <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. t <br /> APPLICATION S <br /> tP,) (For Non-Transferable\Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL rtEALTH 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 /> Business Name (DBA) e��,c €'''��� Address .2- 1: 3 S1 V�� X�� <br /> a Owner �f' �Y�_�, �jl Address <br /> P - �� .�� �>`7�'� /� <br /> Firm Partners, Addresses and Telephone Numbers <br /> ir <br /> a. Business Telephone No. � Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) ' Title �� T.r'�C/-sem Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information -).AMMCE'S SEPTIC & q_B%'E' S SMVICE y/ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) s 1r, ¢, KN5' O <br /> For July 1, June 30, 19 Disposal Sites <br /> i <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, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored 1 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. P <br /> Test Location Test Date/Time (� <br /> 4. ❑ SANITATION PERMIT <br /> Job Addrg s/Locatio <br /> O ner Lam— Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT r <br /> PERMANENT ❑ TEMPORARY JWNEW ❑ REPAIR ❑ OTHER <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 /> Where Certified <br /> Operator Name <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 /> 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 nd regulations of the San Joa uin Local Health District <br /> Ci JiirL� .J..i 11 e. <br /> APPLICANT'S SIGNATURE X <br /> CAL _1� FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> q / DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS x- <br /> PRORATION <br /> PLUS <br /> PENALTY j <br /> OTHER l`t ' a%➢�- ! " .B m <br /> f d <br /> OTHER <br /> — -714 \NI-Se-71 <br /> Received by Date Receipt No. Permit No. Issuance bate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 >! <br />