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Applications WIII'Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.- <br /> APPLICATION <br /> pplication.-APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> /D BTW LIQUID WASTE —33Cs~ C7 <br /> Application is hgreb made to carry on business in the jurisdictional area of the San Joaquin Local Health District, <br /> rBusine'ss Name (DBA) dLGCr�+� Y Address <br /> aOwned' . `�• Address_ y <br /> U Firm Partners, Addresses and Telephone Numbers <br /> EL Business Telephone No. +-� � Emergency Telephone No. y <br /> j Contractor Licence No. j ` - r11- <br /> Title Date <br /> Applicants Name (Print) 1.. w :. <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> I. ❑��PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ;Ily 1 June 30, 19 Disposal Sites ' <br /> For Jj <br /> Descritttption(MakelYr., Color) <br /> Serial,No. CAL. License No. CAL. License Renewal No. <br /> Capaclt Gal.,Weights &Measures No. !� <br /> Equipment Parking Address �" } <br /> 2. 5PUMPER YARD <br /> ----.� - <br /> For July 1, June 30, 19 <br /> .I 7 <br /> No. off!Vehicles Stored <br /> No. of Chemical Toilets Stored � 's; <br /> 3. Eli PERCOLATION TEST _ <br /> R.S. or R.C.E. Name R.S.or R.C.ET <br /> "' � Test Date/Time <br /> Test location <br /> 4. ❑l SANITATION PERMIT c <br /> F (� <br /> Job Address/Location ., r - - I <br /> Owner Address T <br /> �EPTIC TANK ❑ CESSPOOL 1,Qom_ ACHING FIELD ❑ SEEPAGE PIT El PACKAGE PLANTS <br /> 11 PERMANENT 11 TEMPORARY ❑ NEW , PAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July•1'`,-'June 30, 19 ' I <br /> may ... <br /> TypeJConstruction �'- . 'Disposal-Site i • a <br /> t <br /> f <br /> No. df Units _"'6 ' T quipment'Storage/Cleaning Locations) -s- ' S <br /> 6. 0 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 " , F <br /> Operator Name <br /> Where Certified } <br /> Plant!Location <br /> No. Units Served <br /> Plant:Capacity y i <br /> 7. G1 LAUNDRY For July 1, -June 30, 19 <br /> SIZA' ❑ Less Than 1,000•Sq t.; More7han 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 JoaquinCountyR <br /> I ordinances, state laws, and rules and regulavoils of the San Joaquin Local Health District. om <br /> APPLICANT'S SIGNATURE X� '' <br /> ..� .... <br /> } <br /> 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 /> DATE DATE REMITTED AMOUNT <br /> , I <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER �L <br /> i OTHER <br /> i� Received+by Date Receipt No. Permit No. 4ssua ce Date Mailed Delivered \,.r <br /> A APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />