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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 /> f1 ENVIRONMENTAL HEALTH PERMIT <br /> 1' LIQUID WASTE <br /> Application Aihereby mao to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) AddressU� f1]! •C-7� S7i �v <br /> z Owner-.. Address . <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �/ �� 2/ =-- -- Emergency Telephone No. _ <br /> Contractor Licence No. <br /> 1L Applicants Name (Print)_1.92NA116 - ;SAM.D E R 5L Title Z�S'• /W 7Z7A 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 /> i <br /> Serial No. CAL. License No. - <br /> 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 /> est Location — Test Date/Time <br /> 4. 90 SANITATION PERMIT f •'� <br /> bob Addres Location / <br /> 'Owner ddress "J�C2 - <br /> Al SEPTIC TANK ❑ CESSPOOL LEACHING FIELD A SEEPAGE PIT ❑ PACKAGE PLANT <br /> 1WIPERMANENT 0 TEMPORARY 96 NEW 13REPAIR ❑ OTHER d • /Dd G,L 7,a a/�` <br /> f '5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> `Type Construction - Disposal Site `-_--- <br /> No. of Units Equipment Storage/Cleaning Locations) " a <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 _ Z <br /> Operator Name Where Certified �A <br /> Plant Location r rt <br /> Plant Capacity ° No. Units Served <br /> ,7. ❑ LAUNDRY For July 1, -'June 30, 19 '� = <br /> 8 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 0 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 and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> # 1 <br /> r Fee Is Due: 13ANNUALLY ❑ PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> . $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> ..-.. BILLING REMITTANCE.•-DATE-++�+r �+. DATE-^•-�- �-REMITTED AMOUNT <br /> FEE >._� �+ t"' -. k,9 r <br /> LESSS vt 1' <br /> PRORATION \.. <br /> PLUS �� ? <br /> - PENALTY' s <br /> OTHER . �- <br /> i <br /> OTHER I I <br /> Received by Date Receipt No. Permit No, Issu nce a Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON A .Box 2009 STOCKTON,CA 95201 <br />