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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 hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District,, <br /> NBusiness Name (DBA) Address <br /> i Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> a - Emergency Telephone No. <br /> IL Business Telephone No. � - � � --- - - <br /> Contractor Licence No. :. z <br /> Applicants Name (Print} aLG�r✓ ;��.Date <br /> Title <br /> Please check Applicable Category(1-7)"and Fill in the Required Information :. ,_, , r. M.; + �C'� L �� . . <br /> 1. Cl PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; June 30, 19 _ Disposal Sites <br /> Description(Make/Yr.,Calor) I <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights& Measures No. <br /> Equipment Parking Address i <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 y R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location t <br /> Owner-�' Address <br /> o,- <br /> E] SEPTICTANK. 11 CESSPOOL ❑ LEACHING FIELD .tel SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY 1 ❑ NEW 0" REPAIR ? 13 OTHER <br /> i f <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Q <br /> Type Construction ' Disposal Site Equipment Stora Storage/Cleaning Location(s) <br /> No. of Units9 9 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name I : i Where Certified <br /> l or f �w <br /> Plant Location 1 -- <br /> No. Units Served <br /> Plant Capacity 3 ;. <br /> 7. P LAUNDRY For July 1, -June 30, 19-. 'F <br /> SIZE: ❑ Less Than 1,000 Sq- Ft., ❑ More Than 1,000 Sq. Ft. <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 rules and regulations oft an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X I _ <br /> t FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY PER UNIT [_1 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Ju1y 1 &Received By July 31 <br /> IT <br /> - ¢'� NAi"-"- BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLATION ATE DATE REMITTED <br /> rI AMOUNT <br /> FEE -* ..-i le J <br /> LESS f� <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> . I <br /> OTHER - <br /> Received by at - 'Receipt No. Permit No. tss n Dat -Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.-,P.O.Box 2009 STOCKTON,CA 95201 <br /> r <br />