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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 /> Applicatio ts h reby made to c ry oj1� iness i e jurisdictional area of the S�J aquir ocal Health District <br /> Business Name (DBA) � �;SCS ( �+'I � Address �� c, <br /> z Owner Address � e ) <br /> a <br /> .Firm Partners, Addresses and Telephone Nu rs <br /> a. Business Telephone No. 132 r G5 V Emergency Telephone No. <br /> Contractor Licence NO. -13 C7�$ i <br /> K Applicants Name(Print) / i en (Z ' ���G If e— Title Date If <br /> 4 Please check Applicable Category (1-7) and F!11 in the Required Information ' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> li Description(Make/Yr., Color) - <br /> Serial No. � 2 CAL. License No. CAL. License Renewal No. <br /> I Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address fu <br /> 2. ❑ PUMPER YARD <br /> -For July 1,_ June 30,-19 <br /> No. of Vehicles Stored t <br /> No. of Chemical Toilets Stored I <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. ❑ SANITATION PERMIT <br /> Job Address/Location _/ -2 30 i4m J20 <br /> Owner A fZr �'��l !4 r f(C� : Address � � <br />` II SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE--F,IT ❑ PACKAGE PLANT „[ <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER GH*%_ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> I Type Construction $ Disposal Site r <br /> No. of Units k` Equipment Storage/Cleaning Location(s)bi <br /> Ae <br /> 6. ❑ PACKAGE TREATMENT PLANT For July-1,,-June 30, 19 <br /> > <br /> Operator Name Where Certified r <br /> Y_ <br /> Plant Location fA i1*01 <br /> Plant Capacity ) eNo. Units Served` F� <br /> i 7. ❑ LAUNDRY For July T,-June 30, 19 <br /> SIZE: ❑ Less Than 1,00 Sq. Ft., ❑ More Than 1,000*SgFi <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r i <br /> I hereby certify that I have prepared this application and that a ork will k}e done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San�Jin!iLoca l Health District. <br /> APPLICANT'S SIGNATURE X <br /> T <br /> M t f <br /> FOR DEPARTMENT USE ONLY <br /> ElJa <br /> I Fee Is Due: ANNUALLY' ❑ PER UNIT ya PER SITE ❑ EACH I❑ nu1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE .. DATE REMITTED .AMOUNT DUE CHECKED <br /> r AMOUNT <br /> FEE. j <br /> LESS <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> j� <br /> OTHER <br /> 7 l� 71 /0/93 <br /> } Received by Date Receipt No. Permit No, Issua ce Date Mailed eliver d <br /> 1601 E.HAZELTON AVE:,P.O.Box 2004 STOCKTON,C 95241 <br /> APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br /> f <br />