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ations.Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Applic APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> A - lication is hereby made to carry on business in the jurisdictional area of the Son Joaquinj-ocal Health D is1trict <br /> pp <br /> WFBusiniess Name (DBA) 1!11 Ll__Z� Address <br /> Address <br /> z Owner <br /> 9 <br /> Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephone No. <br /> m Business Telephone No. <br /> < <br /> -i Contractor Licence No. <br /> Date <br /> Title <br /> Applicants Name (Print)———4-1 <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. 1:1 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,_June 30, 19 Disposal Sites <br /> Description Make/Yr., Color) CAL. License No. CAL. License Renewal.No. <br /> Serial No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. 0 PUMPER YARD <br /> For July 1,_ June 30, 19 <br /> Nd.-ol Vehicles Stored <br /> Chemical Toilets Stored <br /> 3.�11 PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> II.-PANITATION PERMIT <br /> .Job Address/Location Ad _17 !I-.Tty <br /> IT I Addres�s <br /> r 'I'd(, F:ir d �17PIT <br /> 1, Ow r _"L, _L 0 PACKAGE PLANT <br /> *V, 0 M11- _ D 11 SEEPAGE PIT <br /> O'SEPTICT' ANK 11 CESSP OL LEACHING FIELD REPAIR 0 OTHM <br /> 13 PERMANENT E] TEMPORARY NEW <br /> 5, 0 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> i Disposal Site <br /> I Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> For July 1, -June 30, 19 <br /> 6. 0 PACKAGE TREATMENT PLANT Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> plant Capacity <br /> 7. 13 LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 0 Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br /> 4 13 DAY CLEANING, Chemicals Used/Amount/Mo. <br /> z <br /> dance with San Joaquin County <br /> I'hereby certify that I have prepared this application and that the-work will be done in accor <br /> ordinances, state laws, and rules.and u __ - ___ c <br /> -Letgglations of the San Joaq ifi Local Health Distri t. <br /> APPLICANT'S SIGNATURE X <br /> -FOR DEPARTMENT_USE_ONLY� <br /> anuary 31 July 1 &Received By iu�y 31 <br /> fee is Due-. 0 ANNUAl,_LY 0 PER UNIT PER SITE F-1 EACH' January 1 &Received By J REMIT <br /> I BILLING RFMITTANG $ AMOUNTIDUE CHECKED <br /> I BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No� issuance Date Mailed A 95201 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL KEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C <br />