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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> I (For Non-Transferable, Revocable,•and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE A <br /> Application is hereby made to car on busine in the juris ictional area of the San Joaquin Local Health District�,. .t , + <br /> r re Business Name(DBA)LF—CL C- �Addres1s 1 <br /> a Owner k Address�� � LQ* _Q J <br /> J Firm Partners, Addresses an�Te ephone Numbers <br /> cBusiness Telephone No. S �w r�i-j Emergency Telephone No. <br /> Contractor Licence No. _ <br /> 'Applicants Name (P.(int)._ MdL\ � L Title ©ate <br /> Please check Applicable Category (1-7):and FiII in the Required Information,n .. ,, <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. 4 CAL. License Renewal No. <br /> Capacity <br /> Equipment.Parking Address <br /> 2. ❑ PUMPER YARD <br /> 'For July 1, -. - --June 30. 19— <br /> No. <br /> 0, 19� r - <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored -t ' <br /> 3. ❑ PERCOLATION TEST - -- .. <br /> R.S.or R.C.E. Name '= t R.S. or R.C.E. No. i <br /> `. <br /> TesttLocation I Test Date/Time I <br /> 4. ❑ SANITATION PERMiT ` L + I c <br /> Job Address/Location r , _� t <br /> OwnFer ) Address �y I <br /> 0-SEPTIC TANK ❑ CESSPOOL [,LEACHING FIELD �SEEPAGE-PIT 1:1 PACKAGE PLANT <br /> ❑ PERMANENT 11 TEMPORARY ( ❑ NEW REPAIR ' ❑ OTHER t <br /> 5. CHEMICAL TOILETS For July 1, -June 30, 19 { <br /> Type Construction Disposal Site "r <br /> r E <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6.- El PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name = Where.'Certified € <br /> Plant Location Y i <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 /> 0.DORY CLEANING, Chemicals Used/Amount/Mo. ) t <br /> hereby certify that I ha a prepared this appli6ation•and t_th451or—will be-done in accordance with San Joaquin County # <br /> _ I — <br /> ordinance -state laws and?ule�s�n gegtlatig f tf3e�5ar5 Joaq o al, ealth District., <br /> t <br /> APPLICANT'S SIGNATURE X _ <br /> r - FOR DEPARTMENT USE ONLY <br /> Fee Is_Due: ❑ ANNUALLY ❑ PER`UNIT! ❑ PER SITE ❑ EACH I] January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> r REMIT r <br /> t BASE r ,EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED ; <br /> DATE DATE .REMfTTED s <br /> ` AMOUNT } <br /> ff FEE- JIL L6 <br /> ..E. LESS <br /> PRORATION <br /> I PLUS"! s'+ _., ,► ^` '"•. t. -` , -t <br /> t, PENALTY <br /> OTHERel <br /> OTHER Y 4 f } <br /> Received�by Date Receipt No. Permit No & Issuance Date Mailed Delivered <br /> 11 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES X1601 E.HAZELTON AVE.,P.O.Box 2005 STOCKTON,CA 952D1 . <br />