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Applications Will Be ProcessedlWtleri Submitted Properly Completed:-8e Sure To ignTheApplication. <br /> ` <br /> APPLICATION <br /> ' (For Nan-Transferable;.Redocable;and.Suspendable) SEPTAGE <br /> ENVIRONM_ENTAL HEALTH,.PERMIT <br /> LIQUID WASTE <br /> Application is hereby iriade•ta carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Cl S'et�tLic- Kr Rac'1�Y1nP 'mrAddress, <br /> 4 Owner, -- 'T CDo a Address SS <br /> a Firm Partners, Addresses and Telephone Numbers i T <br /> aBusiness Telephone-Nd. 931Emergency Telephone No. 9 5 7- <br /> Contractor Licence No. 1:3 36 7 "v <br /> a Applicants Name Print `I' <br /> PP (Print) » �pQ� d Title YLPr Date', 1� <br /> Please check Applicable Category�l-7)"and Fill in'the Requlred,tnformation t' n <L' <br /> 1. ❑ PUMPER VEHICLE P�E�GAIT REGISTRATION (FOR EACH,VEHICLE) <br /> For July 1, - June'30; 19- - = Disposal Sites �k•: - - 1 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal Np: . <br /> Capacity' Gal., Weights & Measures No. h <br /> Equipment Parking Address <br /> - r <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored b tM <br />{ No. of Chemical Toilets Stored - <br /> 3. ❑ PERCOLATION TEST t <br /> R.S. or R.C.E. Name f . ._- I R.S. or R.C.E. No. <br /> Test LBcation Test'Date/Time ._ <br /> 4. ❑ SANITATION',IPERMIT <br /> Job Address/Loca)ion <br /> Ownr Address t <br /> DS EPT�TANK C SSPOOL ❑ LEACHING FIELD 11SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ P.ERMANENT ❑ TEMPORARY i ❑ NEW Z-REPAIR f❑rOTHER <br /> 5. ❑ CHEMICAL TOILETS For Julyi;-June 30,:19 <br /> Type Construction Disposal Site <br /> 4 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ) <br /> Operator Name ' Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30_19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ftp 0 rMore``Than 1,0005q. Ft. ' <br /> ❑ DRY CLEANING, Chemicals Used/AmoCint/Mo. <br /> I hereby certify that l'have prepared this application and that the work will be done in'-accordance wlth.San Joaquin County <br /> ordinances, state laws, rule and regulativ of-the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X � 'a �.-� �'�; �• �i X; � " <br /> ` ..FOR Df:PARTMENT 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> Yi'_- - .DATE- v DATE REMITTED - AMOUNT <br /> FEE <br /> f LESS r <br /> PRORATION <br /> PLUS <br /> PENALTY ` <br /> r <br /> OTHER <br /> OTHER - <br /> bi �1 <br /> ecejv Date :Receipt No, Permit No. I Issuanob Date Mailed Delivered <br /> APPLICA — N"ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.eoi M69 STOCKTON,'CA 95201 <br />