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L.y fv ,. <br /> F -'Applications Will Be Processed When Submitted•RroperfyCompleted. e u _ <br /> E APPLICATION <br /> . .. (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i hereby made to carry on business in the jurisdictional area of the Sane u Health District <br /> y Address <br /> OBusiness Name (D ) $ <br /> l Address <br /> a Owner <br /> I J Firm Partners, Addresses and Telephone Numbers <br /> R <br /> Business Telephone No. gg ` —`Z` `— Emergency Telephone No. <br /> a l � z. �'�Ltar�d <br /> Contractor Licence No. pate <br /> Title <br /> LAppiicants Name (Print) 4 <br /> Please check Applidable Category (1-7) and Fill in the Required Information �3 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For4Juiy 1, ' --June 30, 19 Disposal Sites <br /> Description; or) CAL. License Renewal No. <br /> Serial No. } �` t CAL. License No. <br /> Capac_Ity414 <br /> Gall,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July i, June 30, 19 ' <br /> l _ <br /> € No. of Vehicles,Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E. No. F <br /> R.S. or R.C.E. Name t <br /> Test lyocation Test Date/Time I r <br /> 4. [E] SANITATION PERMIT 0 <br /> Job Address/Loc ti n <br /> Address �� S <br /> IN- Owner ❑ CES POOL LEACHING FIELD ❑ SEEPAGE PIT <br /> �� 13 PACKAGE PLANT <br /> C <br /> t t&TSEPTIC TANK ,.� 13 OTHER <br /> 13 PERMANENT ❑ TEMPORARY ❑ NEW ` REPAIR <br /> s <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal-Site <br /> Type Construction _ ; <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> l 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30;;9{ <br /> ,7 ) Where Certified <br /> + Operator Name <br /> Plant Location _ I <br /> I, Plant Capacity No. Units Served f <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19- <br /> SIZE: <br /> 9 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.1 <br /> ❑ DRY CLEANING, Chemicals Used/AmouWMO.• <br /> l <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 a regulation f th n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEMiT By Juiy 31 <br /> BILLING REMITTANCE S AMOUNT DUE CHECKED _ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION . <br /> PLUS a - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Iss ante Dat Mailed Delivered <br /> Receipt No. Perrnit No. <br /> �-- Received by Date CES 1601 R.HAZELTON .O.Boz 2009 STOCKTON,CA 95201 <br /> �. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVI <br />