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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ~yr (For Non-Transferable 4gevocable;and Suspendable) SEPTAGE <br /> ` ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application Is h by made to parry qabusiness in the jurisdictional area:of t San Joaquin.Loll Health District ,. <br /> F �. ,WAIS 1 f1_ s . Address 'Q � <br /> m Business Name (DBA) - - r. <br /> Jr <br /> z Owner Address _ _ -- <br /> 9Firm Partners, Addresses and Tele�ne Num e s <br /> CL <br /> Business Telephone NO.. -s 0 Emergency Telephone No. _ <br /> _J Contractor Licence No. <br /> Applicants Name (Print) U. Tltle. �S� 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-r-- - . === ` - Disposal Sites <br /> Description(Make/Yr., Color) _ <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No: �-3.•;. _ <br /> Capacity Gal.,-Weights &Measures No. <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD 's <br /> x ; <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST , <br /> l R.S. or R.C.E.Name R.S. or R.C.E. No. <br /> Test cation a Test Date/Time <br /> 4. SANITATION PERMIT j _,a <br /> FJ 411t Job Addre Location �-/V <br /> � Owner Address <br /> v�qr SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT 0 PACKAGE PLANT <br /> pit PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-,lune 30, 19 <br /> Type Construction ' #s:' I. Disposal Site <br /> No. of Units 'I Equipment Storage/Cleaning Location(s) C <br /> 6. ❑ PACKAGE TREATMENT PLANT' For July 1, -June 30, 19 <br /> Operator Name, Where Certified <br /> Plant Location ; ,. t <br /> k s, <br /> Plant Capacity No: Units Served - <br /> 7. ❑ LAUNDRY For July 1;-"June 30, 119-_ <br /> t SIZE: _ ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.'Ft. <br /> 0 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> • <br /> 41 <br /> I hereby certify that I have prepared this application and that the woek will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rusand reguI tions of a an Joaquin,Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> a FOR DEPARTMENT-USE ONLY lw= <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 /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> :BASE EXPLANATION – <br /> ws•DATE <br /> DATE <br /> REMITTED AMOUNT <br /> iFEE "s --v <br /> i LESS <br /> PRORATION t <br /> PLUS - <br /> PENALTY <br /> OTHER i, ,:y <br /> OTHER <br /> Received by - Date Receipt No. Permit No. Issua a at Mailed Delivered. <br /> } r APPLICANT—AETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT%SERVICES 1601 E.HAZELTON A .Eoa 2009 STOCKTON,CA 96201 <br />