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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> ! APPLICATION <br /> II (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 JQ in.Loccall HealthDistrict <br /> Business Name (DBA) <br /> - :-Address. <br /> R f <br /> aOwner . 04r .1,�4�iL 4�, Address .. W <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. �'' Emergency Telephone No. 'v' <br /> Contractor Licence No. <br /> a - Date �. <br /> Applicants Name (Print) _ Title <br /> Please check Applicable Category(1-7)and Fill in the Required Information r ;. <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. 'tr CAL. License No, CAL. License Renewal No. <br /> Capacity' la Gal., Weights&Measures No. <br /> Equipment Parking AdUress it <br /> -z <br /> 2. <br /> ❑ PUMPER YARD Ii t` <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored! is P <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST g <br /> R.S. or R.C.E. Name I il. "`• R.S. or.R.C.E. No. A <br /> Test Location 7� Test Date/Time <br /> 4. ❑ SANITATION PIERMIT <br /> Job Address/Location �� <br /> O,w�r }' Address r � <br /> iIXSEPTIC TANK E) CESSPOOL LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY P NEW_ ❑ REPAIR �❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction I� Disposal Site 0 <br /> No. of UnitsEquipment Storage/Cleaning Location(s) W <br /> 6. 13PACKAGE TREATMENT PLANT For July 1, -June 30, 19 M <br /> Operator Name C Ji, Where Certified <br /> Plant Location € <br /> Plant Capacity € dE No. Units Served 1 <br /> 7. ElLAUNDRY For July 1, -June 30, 19l <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ' �?•, <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r <br /> t <br /> f { ' <br /> 4• I <br /> i p �• R <br /> I hereby certify that I Piave prepared'fhis a plication and that the work will be done in'accordance with San Jo in County <br /> ordinances, state laws, and rules and reg ion$oJ.1he San Joaquin Local Health District. <br /> V <br /> APPLICANT'S SIGNATURE X `i '' <br /> -t� F ; <br /> ---FOR-DEPAR6ENT-USE-ONLY -- —A,;�» <br /> Fee Is Due: 11 'ANNUALLY I El PNN11. Jan <br /> ERiT ❑ PER SITE .EACH _❑Juary'1-&.Received By Janu ry 31, El July 1 &Received By July 31 <br /> .I �/t�e¢.-"'l 1q `e..r.^. 1� •r � t J� REMIT <br /> I� BILLING REMIT�TANGt `" $ Y AMOUNT. CHECKED <br /> BA�E Y EXPLANATION i <br /> M� DATE ,C DATE. REMITTED �, `AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> \ s <br /> PENALTY <br /> OTHER <br /> _ OTHER <br /> Ret:eived by I Date" Receipt No. Permit No. I5suanc aw Mailed - Delivered <br /> A tCANT$RETURN ALL COFIIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 , <br />