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t 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 /> s ENVIRONMENTAL"HEALTH PERMIT <br /> LIQUID WASTE <br /> iApplication is hereby made t/o'�arry on business in the jurisdictional area of the San J�aqui�cal Health District <br /> Business Name (DBA) �� Z_oe , � �—_ Address d� <br /> z Owner-- r U Address <br /> 9 Firm Partners, Addresses and Telephone Numbers <br /> CL 7 G Emergency Telephone No. <br /> CL Business Telephone No. <br /> Contractor Licence No. <br /> I" �Applicants Name (Print)_ Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information �n <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) l; <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. GAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address A <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 F <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 /> f Test ocation Test Date/Time <br /> I <br /> 4. SANITATION PERMIT <br /> Job Address/Location <br /> Owner P ° all? /1�-° 'lL! N l _ Address <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT I] PACKAGE PLANT <br /> PERMANENT 1:1 TEMPORARY I] NEIN ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS for July 1, -June 30, 19 fi <br /> Type Construction Disposal Site.f <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 /> r Plant Location <br /> Plant Capacity �No. Units Served ' <br /> 7. 11 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 r les and regulations of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> [ - FOR DEPARTMENT USE ONLY <br /> F Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 &Recewed By January 31 El July 1 8 Received By July 31 <br /> REMIT <br /> tl EXPLANATION BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE LESSPRORATIONPLUSPENALTYOTHEROTHER <br /> q Received by Date -• Receipt No. Permit No. Issuance Date Mailed Delivered <br /> . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEiTON AV .Bow 2009 STOCKTON,CA 95201 <br /> - I <br />