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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 ' hereby ma¢e�to carry on business in the jurisdictional area of the fan Joaquin,Lo, I Health District <br /> OF Business Name (DBA) d <z> eke-. Pdd'ress_ 120_5_ <br /> z Owner E,lb _> l.^ Address ) <br /> Firm Partners, Addresses and Telephone Numbers <br /> C6 Business Telephone No. �_�' Emergency Telephone No. <br /> 1 �( <br /> I QCf <br /> Contractor Licence No. <br /> Applicants Name (Print) Title a�j r Date <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. N 'CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> t i <br /> For July 1, June 36,,19 <br /> No. of Vehicles Stored' <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST-4 <br /> R.S. or R.C.E. Name - ` R.S. or R.C.E. No. <br /> Test Location � Test Date/Time <br /> 4. IR SANITATION PERMIT- <br /> Job <br /> ERMIT ,Job Address/Locati-on �r y <br /> Owner re <br /> _ Ad ss l <br /> J4 SEPTIC TANK R;. ❑CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT - ❑ PACKAGE PLANT n , <br /> ❑ PERMANENT ❑ TEMPORARY E] NEW 13 REPAIR ❑ OTHER <br /> 5. ❑ CHEIIAICAI_"TOII`ETS For July 1,-June 30, 19 J (�n1� <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 R 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. - V <br /> Nalns�l+rnerornow-w4 "WW41 n,4uear astla[oltorrirq:'Y ti betTafltl�a wltFmmisWelk iswsuf##I Inot employanyperson <br /> SUr <br /> in CH Awner as to besorrls S� icttfF <br /> t81A1011CTtt8r1 ti'CI en81iti0S laws of caftnim" q <br /> +l;Anntraetor a N&Vur eub cont >agpstun► glrtlt>as Itt10 fletlrwhW -1 VMY"Iff ft Krlp*ahcasf Me wCA 44 which t*pm mst i3 Issued;I shall <br /> emPlotr PerM8ns to worklnan'stampemAian laws of Csltsf4mW <br /> hereby certify that I have prepared this application aj?d tha the work will be done in-accordance with San Joaquin County ' <br /> ordinances, state laws, and rules and regulatio• ovl e aquin Local Heal Dis ict. <br /> APPLICANT'S SIGNATURE X <br /> ,r 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 /> • BILLING REMITTANCE $ REMIT i <br /> r' BASE- EXPLANATION AMOUNT DUE CHECKED - I <br /> DATE_ DATE REMITTED AMOUNT ^ <br /> LESS <br /> - <br /> I <br /> PRORATION- <br /> PLUS t <br /> PENALTY <br /> r / <br /> OTHER µp <br /> OTHERG <br /> . 4 _ <br /> Received by I Date Receipt No.. - Permit No. Iss ance ate Mailed Delivered <br /> APPLICANT_RETURN ALL COPIES TO:' ''ENVIRONMENTAL,HEALTH PERMITISERVICES 1801 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 <br /> I <br />