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Applications Will Be P sled When Submitted Properly Completed. Be SureTo Sign <br /> at <br /> APPLICATION r <br /> (For Non-WTransferable, Revocable, and Suspendable) �'. SEPTAGE <br /> ' VIRONMENTAL HEALTH PERMIT <br /> fLlQulo WASTE <br /> ` � usiness in the area of the San Joaquin Local Health District <br /> Application is hereby made to carry on b I Q <br /> (DBA) f d S Fi7+C Td.� 91 <br /> rf3usiness Name <br /> a �s�'�IS11Sst�S Address <br /> Address <br /> a Owner <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. _ r .�, Emergency Telephone No. <br /> Contractor Licence No. it 4a 5�i.+W Date f"' ^r4 <br /> Title 4 <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. r{y <br /> Capacity Gal.,Weights &Measures No. �+ <br /> Equipment Parking Address j <br /> 2. ❑ PUMPER YARD <br /> For July IL_ June 30, 19 Q �w2 , � Y1s <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Storedb �'g` � <br /> it <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location g �j Test Date/lime <br /> 4. SANITATION PERMIT -7 3 � � Rc-rr r1 R',O s� �A <br /> Job Address/Location �C ' <br /> Owner Address K11 <br /> +�y SEPTIC TANK ❑ CESSPOOL J LEAC I 1FIELD 13 SEEPAGE PIT PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW <br /> ❑ REPAIR C1 OTHER SYt:7" �trS <br /> 5. ❑ CHEMICAL TOILETS for July 1,- June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location{s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served s <br /> Plant Capacity_ <br /> r 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> CN- <br /> r SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 11DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I,.have prepared this applic and that the work will be done in accordance with San Joaquin County J <br /> ordinances, state laws,-and.rules and regulatio s of th San Joaquin Local Health District. /t <br /> o , <br /> APPLICANT'S SIGNATURE X <br /> f <br /> c FOR DEPARTMENT USE ONLY <br /> ' ❑ ❑ ❑ January 1 &Received By January 31 E] July 1 &ReceivedREMIT <br /> 31 <br /> Fee Is Due, ANNUALLY PER UNIT PER SITE ❑ EACH <br /> �- BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> e - <br /> FEE <br /> { LESS w. <br /> PRORATION <br /> ' PLUS <br /> PENALTY -. - - <br /> r OTHER . <br /> OTHER , r <br /> F Issuance Date Mailed Delivered <br /> Date Receipt No. - Permit No . <br /> • Received by 2009 aTOCKTON,CA 2_ 60 E.HAZELTON AVE.,P.O.Bo <br /> PERMIT/ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERV+CES <br />