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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Re_vocable;Fand Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica ion is hereby made to ear on busin in the juns ictional.area of the San,Joaquin Local Health District <br /> �;Business Name (DBA) _ Address,- <br /> aOwner L FI 1 �L�. - _- Address— <br /> Firm Partners, Addresses d Telephone Nu hers <br /> a. Business Telephone No. �-� ~..Emergency Telephone No. <br /> Contractor Licence No. 0 <br /> L Applicants Nfart Date <br /> -�' Please check Applicable Category (1-7)and fill In the Required Information <br /> 1.Y❑.PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 'For Jufy i. � June 30, 19 -- - Disposal Sites--- <br /> Description(Make/Yr., Color) - <br /> Serial No. CAL. License No. ) .r CAL'ticense Renewal No. <br /> Capa`city"" ."""' ._""""""" ",.'•Gal';Weights-&'Measures-No.'- :_� .�-: T '_`-�• �...L-*-�•-- -- `— - - <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No. f Chemical Toilets Stored <br /> 3. t0 PERCOLATION TEST 1_4 t <br /> R.S.,or R.C.E. Name <br /> R.S. or R.C.E. No. } <br /> r � <br /> t Test Date/Time <br /> Test Location ' <br /> 4. ❑ SANITATION PERMIT i : <br /> Job Address/Coca vn r <br /> OwneriA _s Address l t f <br /> ❑ SEPTIC TANK 11CESSPOOL ,❑'LEACHING FIELD ,SEEPAGE PIT ❑ PACKAGE PL-ANT., I '` <br /> i <br /> r� <br /> .0-OTHER ,s" fl <br /> ❑ PERMANENT ❑ TEMPORARY ❑1NEW f REPAIRS k" <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site I „ <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT-For•J.uly 1, -June 30, 19 <br /> Operator Name I E - Where,Certified <br /> I <br /> Plant Location <br /> Plant Capacity No. Un_its Served <br /> 7. 0 LAUNDRY For:July 1, -June30,.-T9 _ - I 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft-,, ❑ M1 <br /> 1re Than x1,000 Sq.Tt. # r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ° <br /> jI hereby ce I have ptepared s application d that the,work-will be done"iri.accordance_w'ith San Jaquin County <br /> ordinances state law , a ul s:a tl reg latio o th an Jo uin V4Kf i Health District. 1� i <br /> APRLICANT'S SIGNATURE <br /> } ~` "' ; <br /> ' FOR�DEPARTMENT-USE,ONLY� ` "i -� <br /> Fee IS Due: ❑ ANNUALLY PER UNIT; 11 PER SITE El EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31-4 <br /> I <br /> REMIT <br /> BASE EXPLBILLING REMITTANCE $ - 1 EXPLANATION BILLING DUr CHECKED <br /> i DATE M DATE REMITTED -Y -- AMOUNT <br /> k{{ �j� y <br /> FEE t.d7j — <br /> LESS `�v��/ f <br /> PRORATION - j' - <br /> E PLUS <br /> f PENALTY <br /> OTHER - f <br /> OTHER <br /> Received by Date I i Receipt No: Permit No Issuance ., Mailed Deliv red <br /> M <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONENTAL HEALTH PERMIT/SERVICES •1601 E.HAZELT P.O.Boa 2009 STOCKTON,CA 95201' _A.ai <br />