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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 J <br /> LIQUID WASTE <br /> Application I her by made to cam o business in the jurisdictional area of the San Joaquin Local Health District <br /> ,n Business Name (DBA) 7, rlJLC MAddress . <br /> aOwner ��e1rL _Address. <br /> Firm Partners, Addresses and Tel Numbers <br /> aBusiness Telephone No. /-z -Emergency Telephone No. <br /> 1 Contractor Licence No. 5 `�, <br /> L Applicants Name (Print) �r .1=�rrf Title Date - <br /> -,'_,, <br /> Please check Applicable Category (1-7)-and Fill in the Required Information, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) w <br /> F For-July.1,. June 30, 19 �Disposai Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. r� T f''-. —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 /> 1 <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. ❑ SANITATION PERMIT <br /> Job Address/Lo ation F <br /> Ow f —;Sd _ 't .Address _ T L { <br /> SEPTIC TANK ❑ CESSPOOL' LEACHING FIELD ElSEEPAGE PIT' PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER f ' <br /> 5. ❑ CHEMICAL TOILETS For July 1,—June 30, 19 t <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 i -Where Certified <br /> Plant Location <br /> Plant Capacity i r 4 No. Units Served <br /> 7. LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than,1,000 Sq. Ft. <br /> ,. <br /> ❑ DRY GLEANING, Chemicals UsedlAmount/Mo: - <br /> hereby certify that I have prepared this a plication Rd`that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regula ns the San Joaquin~Local Health District. <br /> APPLICANT'S SIGNATURE X ` - d + 4 <br /> 09 i <br /> t <br /> '�"FOR-DEPARTMENi=USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31~ ❑ July 1 &Received By July 31 <br /> REMIT <br /> SICCING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE r DATE REMITTED AMOUNT <br /> FEE O- s <br /> ^! i <br /> LESS #OFI <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> e <br /> OTHER ' <br /> n r <br /> 3i 'l/ 3 �► 1 <br /> Received by Date Receipt No. Permit No. -- Issuanc ate Mailed D livered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - j 11301 E:HAZE'To .,P.O.Box 2009 STOCKTON,CA 95201 <br /> • a <br />