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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 Su spendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is hereby made tD carry on business in the.jurisdic_tional area of the San.Joaquin Local Health District <br /> MBusiness Name (DBA) QOL��E1 .11�- s te.I .��:, =•Address �/C ¢��� _ i^Ws • - lS!(P_Lam, <br /> z Owner- a . . Address L:z �•. S 6 tkit c....Ot IZAAd . <br /> a - . __:..':: - _ _ _ _ <br /> u Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. >R-Z3-- 9 8'7. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information,, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> -).. _— <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 CJ emical Toilets Stored <br /> 3. PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. —� f to` _ <br /> Test Location A!00 sou�11�dr;{i' rg n sb ea�4� Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner 1 Address 4 <br /> ❑ SEPTIC TANK ❑ CESSPOOL - ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TE=MPORARY ❑:NEW ❑_ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 is <br /> Plant Capacity - No. Units Served Y <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 {• <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. s - <br /> r_ ,� s <br /> a-� S <br /> 1 <br /> t I hereby certify that I have pre ed this application and that the work Will be done in accordance with San Joaquin County <br /> ordinances, state laws, and :u� nd-re Mations of t�SJoaLinLocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> + - FOR DEPARTMENT.USE ONLY <br /> Fee Is Dile: ❑ 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 /> DAVE DATE REMITTED AMOUNT <br /> FEE - <br /> LESS <br /> PRORATION <br /> PLUS <br /> ` PENALTY <br /> OTHER __.. _ _ .. - <br /> OTHER <br /> Received by pate Receipt No. Permit No. Issuanc a e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZEL AVE.,P.O.BoR 2609 STOCKTON,CA 9520 <br /> l <br />