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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ' APPLICATION <br /> - (For Non-Transferable,_Revocabfe,-end Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name(DBA) —Address <br /> .Address <br /> aOwner a Address + <br /> 70 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No: Emergency Telephone No. <br /> Contractor Licence NO. .. 9.15:6 ;2 _ - <br /> LApplicants Name (Print) <1 si,(�! /e, ` ;Title , Date <br /> Please check Applicable Category (14) and.Fill in.the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June-30,-19 _- - z7-Disposal Sites <br /> r <br /> Description(Make/Yr., Color)_A <br /> Serial No. CAL..License No._ CAL. License Renewal No. <br /> Capacity _ Gal.,Weights. Measures No. <br /> Equ p <br /> 2.11 ❑ PUMPER YARD <br /> Fdr July 1, k= June 30, 19 <br /> No. of Vehicles Stored Y, <br /> No. of Chemicals•Toilets Stored i <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 4 <br /> 4.!,1,P SANITATION PERMIT _ i L .» <br /> Job Address/Location �r.0 G <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑_LEACHING FIELD ❑ SEEPAGE PIT 1' rQ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ RE AIR yw'OTHER VS <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Sitet <br /> No. of Units Equipment Storage/Cleaning Location(s) ,. ... <br /> 6.1❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 � ✓ y <br /> Operator Name Where Certified i <br /> Plant Location -17 <br /> Plant Capacity No. Units Served �� I'T" <br /> T. ❑ LAUNDRY , For July 1, -June 30, 19 }� ( <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> -01DRY CLEANING, Chemicals Used/Amount/Mo. <br /> -t• - I <br /> ( I hereby certify that 1 have prepared this-application and that the work will be done in accordance;with San Joaquin County <br /> ordinances, state laws, and rules and rW61ations of the San Joaquin-Local Health District. E <br /> APPLICANT'S SIGNATURE X ` /�='r�l Z '7 <br /> o FOR DEPARTMENT;USE ONLY ) i <br /> _ I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE' ❑ EACH I❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> r Y - BILLING REMITTANCE .� $ i•,•:`�� <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> n DATE ATE REMITTEPL,� AMOUNT <br /> FEE S P, <br /> + '# LESS <br /> PRORATION ? f v <br /> PLUSq <br /> PENALTY -Tr <br /> �S' <br /> ,f OTHER - ,�! J <br /> OTHER. „ 7� .. �-...« If� y I <br /> 777-TF— <br /> o y <br /> Received by - Date Receipt No. Permit No. Issuagde Dat - Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTALHEALTHPERMIT/SERVICES 1601'E.HAZELTON AVE.,P.O:Box 2009- STOCKTON,CA 85201- <br />