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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> p APPLICATION <br /> (For Non-Transferable, Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I LIQUID wasrE <br /> i Applicat' n is herebym e to car o bus neas in the j risdiction_aI area of the San Joaquin Local Health District <br /> y Business Name (DBA} F7 tL L� Address F I T <br /> aOwner Address Q �. .v <br /> Firm Partners, Addresses an a <br /> P one_Numbers <br /> M Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> w ;Applicants Name (Print} `-Z . . Title <br /> Please check Appli able Category(1-7)and Fill in the Required Information <br /> i <br /> v .0 PUMPE!,-VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) A r, <br /> For July 1, June 30, 19 x t Disposal Sites _ C1 <br /> Description(Make/Yr., Color) J r - <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> `Capacity"- - —Gal;Weights &Measures No:- ^-�-� -- r <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD t "� <br /> For July 1, June 30, 19 i <br /> r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored T r f <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.G.E. Name R.S. or R.C.E. No. <br /> Test'Location Test Date/Time'' t <br /> 4. ❑ SANITATION PERMIT = 1 <br /> Job Address/Location S 9 S Tr i` <br /> Owner Addfess r— r_'' <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD-' ❑ SEEPAGE PIT ❑ PACKAGE PLANT " <br /> [] PERMANENT ❑ TEMPORARY NEW i REPAIR ❑ OTHERS <br /> 5._ 0 CHEMICAL TOILETS For July 1,-June 30, 19 <br /> ,Type Construction 1 Disposal Site ; r Y. <br /> Np. of Units Equipment Storage/Cleaning Location(s) <br /> Cs. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> (Operator Name - -- - Where Certified + <br /> Plant Location 4 a <br /> ;Plant Capacity i : 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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. #' <br /> I hereby ceirtify that hv4e-prepared this appiicatiori a -that-the work will be'done in accordance with San Joaquin County L <br /> y <br /> ordinalues,state laws, nd rue d"a ula Io naq jli Loc Health District:'" 1�; <br /> ( p„3, w•• y T � yg, i <br /> APPLICANT'S SIGNATURE - € <br /> -• f FOR DEPARTMENT USE ONLY <br /> -Fee Is Due: ❑ AN DALLY ❑ PER UNIT ❑ PER SITE' ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> i <br /> - BASE EXPLANATION Rll_L.ING .REMITTANCE $ <br /> REMIT <br /> DATE ' . AMOUNT DUE CHECKED <br /> DATE REMITTED - t <br /> AMOUNT <br /> cI.�I} C o <br /> ai} .FEE . t E V F <br /> L <br /> PRORATION <br /> PLUS 1 <br /> PENALTY U� <br /> a <br /> I OTHERre <br /> fff ? a p <br /> OTHER <br /> 4 Received by ate I Receipt Now ` Permit No. Issuan Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL�HEALTH PERMIT/SERVICES'` '� 1601 E.HAZELT AVE.,P.O.Box 2009 STOCKTON,CA 85201 t <br /> • t <br />