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Applications 1Mill 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 hereby made to carry on busi ess in the jurisdictional area of the S n Jo uin Local Health District <br /> w Business Name (DBA) A /` R R i!!W t'cr��� Address •� '-� 23'zO <br /> loor <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. � � �10 :7 Emergency Telephone No. <br /> Contractor Licence No. S <br /> L Applicants Name(Print) a f- Title • Date Z <br /> Please check Applicable Category (1-7)and Fill in the Required Information <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, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 4 SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL '❑`LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT -F <br /> ❑ PERMANENT ❑ TEMPORARY 0 NEW REPA4)V. _ ❑ OTHER Q <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: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 'S}1MF��h>x� g�s�$��5t^Wa?R' ":?n'"rs "gu'" ..` ;ir,�t w7i ,;;as ;AiF!S!P^`�A �i41'� 'f�:Rif tiFirFfrk;Flu ,7r�,trrt�ltilsi�ihl'GI!1i�9�,`ttS8�1109:��i0!IPJ.3.,�is�i�/`�J# 5����(ii�TSfi?3 <br /> lF1SWCn1�F},,P,f�s�4�;�ef'erntz.�;ul� vit�4Y9.h�laYs.v�lrrr}�;1st'4r�t-t,�,4usfYfy�ut�alr,a: - <br /> ar's ee:St;4e• tt,u "Aa _ '1 cel:Wy th*t;i tlW PaUXI ys X9 of the work for whkh thispyr�t is issued.I shall <br /> 'y Stis s+*0 to W6fkI la^s Ca 1P2nsatie0 taws�f 1i8140rwa:" <br /> f 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 r and regulation of th2_SaQ Joaquin L aI Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY67 <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION- AMOUNT DUE. CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 4 4,_5 <br /> LESS <br /> PRORATION <br /> PLUS U S SO 2 <br /> PENALTY <br /> OTHER <br /> 4 c4 <br /> OTHER <br /> Received by Date Receipt No. Permit No. lVsuance 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 />