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_ Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication <br /> APPLICATION <br /> (For Non-Translerable,-Revocable,,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH, XRMIT <br /> LIQUID WASTE <br /> Application is her b 00 to c4rry n business in the jurisdictional area of the San Joaquin ocal eal h District „ <br /> H Business Name (DBA)�,J%' `��� �- Address• �_ <br /> z �, Address lot/ <br /> a Owner - - � <br /> Firm Partners, dd�ard�Tel'enphon Numbers <br /> aBusiness Telephone No. *� 4 Emergency Telephone No: <br /> Contractor Licence No. - <br /> Applicants Name (Print) ►" Tit <br /> le `:'� Y` Date h; <br /> Please check Applicable Category;(1-7) and Fill in the Required,lnlormation.,�'E, 4 .f j.•Php�Q t: 50J ' (J <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, = June 30, lg" Disposal Sites - - _ <br /> Description(Make/Yr.,Color) <br /> CAL. License No. CAL. License'•Renewai No. <br /> Serial 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 /> No. of'6hemicalrT011etS:StOred *- <br /> 3. ❑ PERCOLATION TEST <br /> :R.S. or R.C.E. Name R S'Dr R.C.E. No. <br /> Tes Location °; T Test Date/Time <br /> r 4. V SANITATION PERMI� �.• � f r u` <br /> Job Address/Location <br /> Ow9. <br /> ner t'���' r I" k " Addres�s{{ <br /> SEPTIC TANK 11CESSPOOL LEACHING FIELD 'RJ SEEPAGEPIT- PACKAG PLANT <br /> PERMANENT C] TEMPORARY ®..NEW ©'REPAIR '= ❑ OTHER 3 <br /> 5. ❑ CHEMICAL.TOILETS For July 1,F June 30, 9 <br /> Type Construction *-' Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1June 30, 19 11 x <br /> Operator Name Where Certified' ; <br /> Plant Location ,,. T_ . <br /> r Plant Capacity No. Units Served =t <br /> 7. ❑ LAUNDRY- For July-1;-June 30, 19= -` - � v ��-�- . 1 � <br /> k SIZE: 0 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.n <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,and regulations of the S n Jo U T ocal Health.District. <br /> APPLICANT'S SIGNATURE X - <br /> _ I t <br /> • FOR DEPARTMENT'USE ONLY r.. <br /> Fee Is Due: ❑ ANNUALLY ❑.PER UNIT ❑ PER SITEI ❑ EACH'r ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jury 31 <br /> A REMIT <br /> BILLING 'REMI.T,TANCE $ <br /> ,BASE _ EXPLANATION.�s r' AMOUNT DUE CHECKED <br /> j <br /> DATE � DATE REMITTED - <br /> AMOUNT e" <br /> FEE / <br /> LESS <br /> PRORATION , <br /> PLUS ; <br /> PENALTY Ai <br /> .. OTHER <br /> /11164 <br /> OTHER <br /> Received by Date - .Receipt Nd' Permit No. i r Issuance Date Mailed Db4w.Ke5 , <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMITI5ERVICES "—'1601 E.HAZELTON AVE.,P.O.Bo=2009 STOCKTON,CA 95201 <br />