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Applications'Will Be Processed When Submitted Properly Completed. BeSureTo Sign ineApp,11-ol <br /> ii APPLICATION <br /> (For Non-Transferable, Aevocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica i n is hereby made o car on bum a in the jurisdictional area of the San Joaq Local alth Distr' s�- <br />` H Busines a (DBA} Address �(� <br /> cOwner Address <br /> 2 Firm Partners, Addresses and` le h Numb rs <br /> Emergency Telephone No. <br /> CL Business Telephone No. n } <br /> Contractor Licence No. 1 Date r <br /> Applicants Name (Print) Title <br /> CLr^R�.i�C�'S St��C � Sci`�1 SERG'�­E <br /> Please check Applicable Category(1-7)and Fill in the quired Information 2F3 Sr,. Oro Stockton, CBill. 957.05 <br /> 1. [1 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE). <br /> PA. 32,1 t r� M <br /> antor's'l in <br /> For July 1, June 30, 19 �Ij Disposal Sites <br /> Description(Make/Yr., Color) j CAL. License Renewal No. <br /> t Serial No. i� CAL. License No. <br /> Capacity_ Gal., Weights A Measures No. <br /> Equipment Parking Address <br /> li <br /> 2. ❑ PUMPER YARD I� <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> f No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. . <br /> Test ocation Ij Test Date/Time <br /> 4. SANITATION PERfIAyj;T �4� <br /> S- \L� " <br /> Job Addr ss/Locati n <br /> Owner Address <br /> O <br /> O ❑ LEACHING FIELD 1:1 SEEPAGE PIT 11 PACKAGE PLANT <br /> Ip1 SEPTIC TANK ❑ CESSPOOL - OTHER Cf� <br /> ❑ PERMANENT ❑ TEMPORARY .NEW K REPAIR _ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _ od <br /> Type Construction Disposal Site <br /> No. of Units l Equipment Storage/Cleaning Locations} <br /> t 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified K <br /> k Operator Name <br /> Plant Location :I� - %- <br /> No. Units Served <br /> Plant Capacity d <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq:i Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> li. <br /> M # <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,�SaArul�U and regulations of the San Joaqui 'ocal Health DistrcLtREI�,CE'S S!A1C a }SER SER��jErAPPLICANT'S SIGNATURE X __~ PA.46-3,-3209 Contractor's Lic.#257177 <br /> FOR DEPARTMENT USE ONLY 3 <br /> s <br /> Fee Is Due: ❑ ANNUALLY�_ ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ Juty 1 &Receiv I'll I By July 31 <br /> ( !I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> j BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> s FEE <br /> LESS <br /> PRORATION "1 <br /> PLUS Ii <br /> PENALTY <br /> OTHER <br /> A <br /> OTHER �• <br /> �. r <br />