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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> APPL'CAT'ON <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin.Local Health District a <br /> wBusiness NameBA) Address <br /> a Owner_ );ley i��l h? 0 1U S Address �. <br /> J Firm Partners, Addresses and Telephone Numbers 3 <br /> i< Business Telephone No. f a `- Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> �o <br /> a Date <br /> Title w <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) �R <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.7C0lOr) <br /> Serial No. I. CAL`License No. CAL. License Renewal No. <br /> Capacity Gal., Weig4its &Measures No. <br /> Equipment Parking Address ' <br /> 1, \•_ <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30;`19 "g <br /> II No. of Vehicles Stored./. - <br /> No. of Chemical Toilets Stored _ <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name r R:S. or R.C.E..No._ <br /> Test Location Test Date/Time `'t <br /> 4. ❑SANITATION PERMIT (' <br /> Job Address/Location <br /> Addres tr ` <br /> i <br /> 11 SEPTIC TANK.—D.CESSPOOL �'LEACHING FIELD PIT ❑`PACKAGE PLANT I. t <br /> C1 PERMANENT 13 TEMPORARY_ ❑ NEW ❑ REPAIR ❑ OTHERI­' <br /> S. 13 CHEMICAL TOILETS For July 1, -June 30, 19 f ' <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) d I 3 <br /> f 6. Cl PACKAGE TREATMENT PLANT For July 1,-June 30, 19 - t-•. ��< f <br /> Operator Name <br /> ...� r. Where,Cer.tified <br /> Plant Location <br /> Plant Capacity No. Units Served 1 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> ❑ Less Than 1,000 Sq. Ft.," ❑ More Than 1,000 Sq. Ft. r <br /> t ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 4i' <br /> HomsownernrC�ensa�?aCc,t !;n*. ,-rnrArt;rsthafLntaIjIrI"IC8rtift '%t,+f>eperfnn-ranceofTt vwurkfor,,Ithis permit tSissued,IshANnot^mpiolany pInr5;5n <br /> in such mannet ids t0 hecerr.e`L5�°v:si! r°t I l-:'�'t-U..^!lER t� :,"'lVg of c .11OrCii.. <br /> j Contractor's hiring-ar s,t-crar trotting 3-im"'Vi �¢ fifty '.a<. :ottetvi�: "i C[;rtl()•that in the performame at the work for wNch this pvr}11it is i,,,uEd J;:I13i1 <br /> f employ pelII subject tc uarklrar.'s <br /> hereby certify that'l h prepay d this application a that the work will be done in accordance with San Joaquin County <br /> ordinances, state law , and ides d re I ns oft an Jeaquin Local Health District: <br /> APPLICANT'S SIGNATURE X <br /> DEPARTMENT USE ONLY - -- <br />' Fee IS DI 11ANNUALLY ElPER UNIT ❑ PER SITE ❑ EACH 13January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - REMIT <br /> BILLING REMITTANCE $ ~ AMOUNT DUE CHECKED <br />] BASE EXPLANATION DATE" ' 'DATE- R IT ED—. <br /> `�' � j � / ` �AMOUNT <br />�. FEE 7� r,. �G�` (� �t LS ! r !� AL­ <br /> LESS <br /> `qI <br /> PRORATION t <br /> PLUS �jl! f � � �'� v -F-- 0 <br /> PENALTY <br /> OTHER 0l t/ e r <br /> e <br /> OTHER41 <br /> ' <br /> t/�'� r!r Pf OW r Ir$ry Gtj �ilwG <br /> i <br /> r <br /> fI i71ori <br /> Received:Ty Datel. Receipt No. a mit No. issuance Date Mailed Delivered <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESTOCKTON,CA 95201 <br /> S •1601 E.HAZELTON AVE.,P.D.Box 2009 <br />