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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application APPLICATION 1..0-� e s (For Non-Transferable,Revocable, and Suspendable) �+M SEPTAGE � ENVIRONMENTAL HEALTH PERMIT U �/ LIQUID WASTE r Applicatio i her de to carry o usines the jurisdictional area of the Sa Qaqui ocal Health District y Business a (DBA)_,C,�P�°.r. y__ !1 Addres Y aOwner c Address u Firm Partners, Addresses and Telephone Numbers a. Business Telephone No. 13 OR3S'':LR __ Emergency Telephone No. Contractor Licence No. &dp.,y 7.Zl - - Applicants Name (Print) a Title es) Date Please check Applicable Category(1-7) and Fill in the Required Information 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) d For July 1, June 30, 19 Disposal Sites Description(Make/Yr., Color) Serial No. CAL. License No. CAL. License Renewal No. Capacity Gal.,Weights & Measures No. Equipment Parking Address 2. ❑ PUMPER YARD For July 1, June 30, 19 No. of Vehicles Stored No. of Chemical Toilets Stored 3. ❑ PERCOLATION TEST R.S. or R.C.E. Name R.S. or R.C.E. No. Test Location Test Date/Time 4. RKANITATION PERMIT Q Job Address/ ocat'ion � Owner— Address - Ov21" " fSEPTIC TANK ElCESSPOOL 8LEACHING FIELD 11SEEPAGE PIT ❑ PACKAGf PLANT _-ZI RIPERMANENT ❑ TEMPORARY ❑ NEW U REPAIR ®-OTHER $"-70 F� 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Type Construction Disposal Site No. of Units Equipment Storage/Cleaning Location(s) G. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 Operator Name Where Certified Plant Location Plant Capacity No. Units Served 7. ❑ LAUNDRY For July 1, -June 30, 19 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ❑ DRY CLEANING, Chemicals Used/Amount/Mo. I hereby certify that I have p red this appli ion and that the work will be done i ; ccordance with San Joaquin County ordinances, state laws, rul and.regulati he Joaquin Local Health DIs ri APPLICANT'S SIGNATURE Wz FOR DEPARTMENT 0 LY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH jYJanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING EMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED I AMOUNT O f FEE 0 LESS PRORATION PLUS PENALTY ` OTHER r OTHER x.. .2 V Received by Date Receipt No. Permit No. ll1sst1ancqUatcl Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 .