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k Applications Will Be Processed When Submitted Properlycompletea. tiesure IuJFU711 IFIC.,rNFF.o.,...,• + <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> • ENVIRONMENTAL HEALTH PERMIT <br /> ft LIQUID WASTE <br /> Application is hereby made to carry on b si s in the jurisdictional area of the San Joaquin Local Health District <br /> 4!-, Business Name (DBA) SAN J0AQl IT N P Address 860 F PINEI DT]TTf A Q574l1 <br /> i Owne0-Q. Address $6C F PI <br /> a <br /> a Firm Partners, Addresses and Telephone Numbers <br /> a Emergency Telephone No. <br /> a Business Telephone No. <br /> 1 Contractor Licence No. <br /> LApplicants Name (Print) Title — MGR Date <br /> Please check Applicable Category (1-7) and F I the R u1 Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGIST N (FO A VEHICLE) <br /> For July 1, June 30, 19 al S s <br /> Description(Make/Yr.,Color) <br /> , L' CAL. Licc Ise Renewal No. <br /> Serial No. ense No. <br /> Capacity I., -ei &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stor _ <br /> 3. ❑ PERCOLATION TE <br /> R.S. or R.C.E. Name �jJ R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. )p SANITATION P MI <br /> Job Address/Location END OF ROAD ON -SOUTH SIDE <br /> Owner Address <br /> ❑ SEPTIC TANK CE OOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT TE RARY ❑ NEW (REPAIR ❑ OTHER REPAIR/REPLACE DOMESTIC PUMP <br /> 5. ❑ CHEMI ILEI � Far July 1,- June 30, 19 <br /> Type Construin,n Disposal.Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACK TREA MENT PLANT For July 1, -June 30, 19 <br /> Operator ame Where Certified <br /> Plant Loc n <br /> Plant Capa y <br /> No. Units Served <br /> 7. ❑ Lkp DRY or July 1, -June 30, 19 <br /> SIZE: Less han 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ Y EANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> �r ordinances, state laws, a rules and re ulations of the San Jo uin Local Health District. <br /> t <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201 <br />