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k Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> t APPLICATION <br /> S (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i LIQUID WASTE <br /> a � <br /> Appl icati n ' h r by made to r n usiness in the jur fictional area of theSan Joaquin Lo al Ilealth District <br /> �Business N me (DBA) Address <br /> 4 A. <br /> z Owner Address <br /> I <br /> J Firm Partners, Addresses Telephone Numbers <br /> 6. Business Telephone No. ` l Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title 66d 5X Date <br /> 42 <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <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. t <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 /> � I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name h R.S. or R.0 E. No. <br /> k Test Location + Test bate/Time <br /> 4. 04 SANITATION PERMITr <br /> Job Add r s/Locatio <br /> 7 � # �� <br /> f Owner — s ` 4 Address t Q_ <br /> SEPTIC TANK J❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE-PIT ❑ PACKAGE PLANT C <br /> ❑ PERMANENT ❑ TEMPORARY # NEW E] REPAIR ❑ OTHER <br /> 5. ElCHEMICAL TOILETS For July 1, -June 30, 19 1 -r <br /> + Type Construction t Disposal Site F! IL ; <br /> Y' <br /> No. of Units ^ Equipment Storage/Cleani1 <br /> Operator Name ng 1_7o'Uion.(s) � <br /> 6. 13PACKAGE TREATMENT PLANT For July 1, -June 30, 19`! �} I <br /> I f ' Where Certified <br /> i 4 � <br /> Plant Location .•ti,-...I II I I D <br /> Plant Capacity ftr No. Units Served��.�.. #_ <br /> 7. ❑ LAUNDRY For July 1, -June 301,,19- 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., [],More Than 1,000 Sq. t. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO.j' SS <br /> Irl�.AAr„ ( . <br /> I t f <br /> I hereby certify that I have prepared this application andUhat the work will be'.done in accordance-with.San Joaquin County <br /> ordinances, state laws, and rules an regulations of the Sa. 4oa Local Health Distri ft` <br /> F APPLICANT'S SIGNATURE '` <br /> dIF <br /> r - <br /> .�F' .v` <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS rr <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> —io 1 —7 <br /> Received by I Date I Receipt No. Permit No. Issuance Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ww STOCKTON,CA 95201 - <br />