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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Apptication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio ereby made to carrygn busin s in the jurisdictional area of the an Joaquin cal H alth Disitrict <br /> HBusiness me (DBA) I < � ' Address r 7� <br /> aOwner Address - - C <br /> J Firm Partners, Addresses and Telephones Numbers 9y� ✓ <br /> aBusiness Tel No. 9Qa^ 3 Emergency Telephone No. <br /> Contractor Licence No. /? ?� <br /> L Applicants Name (Print) r�'�— �! cnn- Ego Title P k 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. 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 .L <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. ❑ SANITATION PEF MITa- <br /> Job Address/Location 1 E '7 , S` .r rr N <br /> Owner Address <br /> 11 SEPTIC TANK ❑ CESSPOO LEACHING FIELD ,�..�,,,�S,..EEPAGE PIT 101 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 0sREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 ��11 <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 /> 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 X _ ` <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> (�"t <br /> FEE — L4 S ` -S <br /> LESS <br /> PRORATION O <br /> PLUS <br /> PENALTY _jam r7 <br /> OTHER <br /> OTHER <br /> 'PAy )_ 1 Z)_3 C) C) <br /> Received by D to I Receipt No. Permit No. Issulince Datt Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box2009 STOCKTON,CA 95201 <br />