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�- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION ° <br /> (For Non-Tran sfeiabte 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 <br /> Business Name (DBA) ': ✓ i/-GE cT'®�/ _ Address <br /> a Owner , Address. _ <br /> ,.. <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. � Emergency Telephone No, <br /> Contractor Licence No. a "'ff z - <br /> LApplicants Name (Print) i i_ Title ~� <br /> Date <br /> s` ~' <br /> Please check Applicable Category (1-7)and fill in the Required Information; <br /> 10 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 0 <br /> For July 1, June 30, 19 = Disposal Sites- <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 <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 /> 4. W SANITATION PERMIT <br /> Job Address/Location .2 G 77� s J- S7aGfc7'A/ <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING'FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR E .OTHER 440A1Pe L1 �-A l r,77 uG- <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 moo/C u/-, 7-4v SeAIAE� <br /> Type Construction .-Disposal Site <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 ' f � <br /> Plant Capacity f_ No. Units Served <br /> 7. ❑ LAUNDRY For July I'-June-30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑`More Than 1_,000 Sq. Ft. <br /> f <br /> ❑ DRY CLEANING, 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 /> ordinances, state laws, and ruleand reau tions of th a Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> + t FOR DEPARTMENT USE ONLY 1. <br /> Fee Is Due: ❑ ANNUALLY_ ❑ PER UNIT ❑ PER SITE ❑ EACH __ ❑ January 1 &Received January 31 ❑ July 1 &Received By July 31 <br /> BILLING RE�,DATE <br /> $ REMIT <br /> Y BASE EXPLANATION DATE REMITTED AMOUNT DUE CHECKED <br /> { AMOUNT <br /> -FEEl L `a a } <br /> LESS hh Q ` - <br /> PRORATION {PLUS <br /> PENALTY /Vi”L f hL6fJ <br /> �e�'r.l�Ccfiaf, .�9cFc <br /> OTHER <br /> OTHER <br /> /01 U r'V <br /> alive N�J�16 <br /> Received lay - Date Receipt No- Permit No. Issuan e D MaileJ <br /> APPLICANT—RETURN ALL COPIES TO:-- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTO . P.O.Box 2009 STOCKTON, 95201 <br />