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—Appli a ns Will Be Processed When Submitted Pro <br /> IQNpleted. Be Sure lobig" ','mac .•• •" <br /> APPLIC <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 1 ; <br /> LIQUID WASTE fJQ <br /> Application is her made to carryon business in the jurisdictional area of the n Joaquin Loc �al e �h District <br /> t <br /> ��• zJ,l !< Address <br /> rBusiness Name.(DBA) _ 41 , , <br /> rn -" /k Address ""� <br /> � <br /> i Owner <br /> 0 Firm;.Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. �.� l 1 y •-•< <br /> contractor Licence No. "- r^ Title /7 c_'✓ 1]-✓>. Date <br /> Applicants Name (Print) - <br /> ,.Please`check Appilegible Category (1-7)and Fill in the Required Information <br /> 4 ;• 1. ❑ PUMPER,'VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1 <br /> June 30, 19 Disposal Sites <br /> Description-IMil Colo . <br /> r) CAL. License No. CALLicense Renewal No. <br /> ke/Yr., <br /> Serial NO,'."'t'''L" <br /> Capacity °' Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> I` 2, ❑ PUMPER YARD t <br />'€ For July 1, June 30, 19 <br /> No. of Vehicles Stored.. <br />+ No. of Chemical Toilets Stored rr. <br /> 3.. 13 PERCOLATION TEST s R.S.or R.C.E. No. <br /> R.S. or R.G.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT f-� r19 <br /> Job Address/Location <br /> i 11 V7 r Address <br /> Ower ©-LEACHING FIELD 11SEEPAGE PIT ❑ PACKAGE PLANT / <br /> M SEPTIC TANK ❑ CESSPOOL 0 NEW ❑ REPAIR ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY <br /> > 5, ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> i . - .Disposal Site <br /> Type Construction _ <br /> � s) <br /> Equipment Storage/Cleaning Location <br /> No. of Units-.----- <br /> g• ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name _ <br /> Plant Location" } -� — -�--- r —No -Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 �. <br /> t 'SIZE: [l-Less.Than 1,000 Sq. d., ❑ More Than 1,000 Sq. Ft. ..,� <br /> f T❑.DRY CLEANING,"Chemicals Used/Amount/Mo. <br /> with San Joaquin County <br /> I hereby certify that I have prepared this applica�n and that-the work will be done in accordance <br /> ordinances, state caws, and rules and reg latios.of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ✓ <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due' EI ANNUALLY ❑ PER UNIT �O--PER-SITE [IEACH-- L v❑ January 1 &Received y January 31 ❑ July t &ReceiveR�EMIBy TuIy 37{ <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> f BASE EXPLANATION DATE 'DATE MiTTEQ AMOUNT <br /> I [� <br /> S <br /> FEE <br /> LESS 1 ; <br /> PRORATION <br /> PLUS <br /> t- PENALTY <br /> iL y' <br /> OTHER <br /> { OTH77 <br /> ER - - - - - - . <br /> 7 f <br /> a O .• D red <br /> p <br /> Permit o. issuance ate Mail <br /> { Date Receipt No. CA 95201 <br /> Receivedby 1fiD1 E.HAZELTON'AYE.,P.0.8oi 2009 STOCKTON, <br /> APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />