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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is her y made to carryon usiness in the jurisdictioal area of the San Joaquin Local Health District <br /> OBusiness Name (DBA) ��—�i r Address <br /> aOwner _ Address <br /> Firm Partners, Addresses and Telephone Number , <br /> CL <br /> Business Telephone No. A- 3 Emergency Telephone No... <br /> Contractor Licence No. z <br /> Applicants Name (Print) G Title Date <br /> Please check Applicable Category (1-7)and Fill in the Re ired Information T <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) S <br /> For July 1, June 30, 19 -- -Disposal Sitest <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 l <br /> No. of Vehicles Stored <br /> 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 Location Test Date/.Time <br /> k- apt <br /> 4. )6 SANITATION PERMIT <br /> 'Job Address/Locatio� T ? <br /> O ner �tJ ' Address <br /> SEPTIC TANK ❑ 6ESSPOOL LEACHING FIELD ❑ SEEPAGETPIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 10 NEW 7_,1:y O;<REPAIIR ❑ OTHER r <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 /> Ii. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name — r"""- Where Certified j <br /> Planttocation <br /> PlanVGapacity No;-.Units Served t <br /> 7. 2.7LAUNDRY For July 1, -June 30, 19 �. <br /> SIZE''4 ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ff <br /> DRY CLEVIINNG, Chemicals Used/Amount/Mo. <br /> nwnlrotFfoense�and[m"a�tQnelt�r9r,�.;r, 1 <br /> in such manger a5 t4 t cane , I e"he 1-tllp.tt I fi, I v j <br /> Conerattorm hi saa;r�rt`o�"ort r`�Ifis�n.;,1 ,.;Ionfjv,r r'rt.t,th,^4 ,hP�tPrtorinanceL'tthe wurk'or+ !rictithispermit isissued,Ishall no:employanypmun # <br /> 1= } t .1�C"5 D "?T7fnlnl <br /> or a uh enntrt h..irtgt C3ay r n*r +;r. ti !. <br /> t ABYpersons suD tato%VUk:ttan s crn ui3ti.=ry i c"Etily tha:in the ertormance of the tvark far which <br /> ♦ , P <br /> ,, a, h chis permit i�issued.I shall <br /> I hereby certify that I have prepared this application and that the Wark +mill be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules andr ulati s of t e San Joaquin Llocal.-Health District. <br /> , t L4 i <br /> APPLICANT'S SIGNATURE X `� r <br /> FOR DEPARTMENT USE ONLY p <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July,1 &Received By July 31 t <br /> BILLING REMITTANCE <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - - <br /> OTHER <br /> OTHER <br /> i S <br /> Received by Date - Receipt No. Permit No. Is uanc6 Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 I <br /> i <br />