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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application: <br /> APPLICATION <br /> (For Non-T-rans7e7$ie, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> -`La.4 W. s,.. LIQUID WASTE I 2210 —oq <br /> Application is �reb-y_mad o car n business i the jurisdictional area of th an J quip oc I He�+t�h istri <br /> yBusiness Name (DBA) 9 i _ .f.,., Address -® 4far Sao! - <br /> aOwner Address <br /> J Firm Partners, Addresses and Tel h ne N mbers , <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) vE ' Title .Date 9WIa' <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Lw <br /> For July 1, - June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL- License No. CAL. License Renewal No. <br /> i Capacity Gal.,Weights &Measures No. 1 <br /> s Equipment Parking Address Vi <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name € �. _R.$i or R.C.E. No. <br /> Test cation t T'est_pate/Time <br /> 4. SANITATION P MIT' ` '�V' x k 4 1 4 <br /> `Job Address ocation r4T b 1� C `; <br /> OwnerAddress�• • <br /> 0 SEPTIC'TANK- •❑ CESSPOOL LEACHING FIELD,,X-S��EEPAGE PIT ❑ PACKAGEIPI AN_T_ j , <br /> PERMANENT ❑ TEMPORARY ElNEW i ��iEPAIR W OTHER fie,- nc6&4-444zf e_ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal:Site ,,0 <br /> No. of Units Equipment Storage/Cleaning Locations) t'A <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 i <br /> Operator.Name _ Where Certified <br /> Plant Location Z ---r <br /> - a. � _. _..-_ <br /> Plant Capacity 1 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. r <br /> .❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> HoateovmerorSiccsssodsga�t'sPII0n3'.BretP!'if?Islha}a;lr,. 'r ;'Icerflfv!;l-11initheptlr:T-rmaroe nf#11swtorkforwhich tbispermitisi;sU01S!:alI tCIMp?C�y2ay,lrr->q,+ <br /> In <br /> suc;1 rtlaPIIeT a5 !IC]f118 5Itij6it t0;9z3, -n J.n,t�ln] S f ,I ia�v i Lj{ fn1 <br /> CaRtractor's thE6esg a: Null-ccitrac:in .:?�a r� 3S (+ r.._ x "'i:'J thui ,ffic perfurn a.nce or the.-,vork far whiCh;i}i H`-'rrrit Is ued:'8}10 <br /> employ persons iS;4Ci t0'podr rnap"5 r.:, y. i:" <br /> I-hereby certify that I have prepared this a4llcatloh!and that"the work will be done in accordance with San Joaquin County <br /> T ordinances, state laws, and rules and r guMfiol�the&� nJoEiquin Local Health District.APPLICANT'S SIGNATURE X I <br /> e <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE, ❑ EACH ❑ January 1 &Received By-January 37 31I July 1 &ReceSved 13y July 31 <br /> f' REMIT <br /> 3 BILLING REMITTANCE $ <br /> BASE EXPLANATION € IMOUNT DUE CHECKED <br /> DATE —�. DATE REMITTEDw_ <br /> �_ .. i - AMOUNT i <br /> FEE � - �. -i .�,.•:--•-+-.- t <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> i i <br /> OTHER � I <br /> OTHER <br /> Received by Date Receipt No. Permit No. �, Issuan Date ailed Delivered <br /> APPLICANT ALL-COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AY . .Box 2009 STOCKTON,CA 95201 - - <br />