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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.�,.�. <br /> , . APPLICATION <br /> (For Non-Transferable;Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby madetocarry on busine the l'urisdictional,area of the.San Joaquin Local Health.District. - t, t,y4 <br /> On BusinesspNape.(DBA) vn r Address <br /> z Owner Cir► ,. CnF Ac�4� s <br /> 0 Firm Partners, Addresses and Telephone Numbers x <br /> a Business Telephone No A -_ Emergency Telephone No . T <br /> Contractor Licence No. . <br /> LApplicants Name (Print) I ' Titie --!f,.Date <br /> Please check Applicable Category (1-7).-and Fill,in the Required-Information.,. .;,, - , s• ,�;D �1.t ;, - : <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, "'June 30;19- _ �_ "�`•-- Disposal Sites - - - <br /> Description(Make/Yr., Color) I _ <br /> Serial No.' CAL. License No. CAL. License Renewal 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 Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST i <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> p Tet Lcation 1 - Test Date/Time <br /> 4 4. SANITATION PERMIT <br /> Job Address/.Locati <br /> O ner Address <br /> L SEPTIC TANK- ❑ CESSPOOL ❑ LEACHING FIELD © SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY_ 13NEW ❑ REPAIR MOTHER 105. El CHEMICAL TOILETS For July- _June 30, 19 1 �1, ss <br /> Type Construction Disposal Site - <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> i <br /> i Plant Location r 1 <br /> L Plant Capacity No. Units Served <br /> I <br /> J. ❑ LAUNDRY For July 1, -June 30, 19 - <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., 13 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I e epar icatio tha o e done in accordance with San Joaquin County <br /> ordinances, state la an a n o Local H alth District. <br /> APPLICANT'S SIGNATURE X <br />{ <br /> FOR DEPARTMENT USE ONLY <br /> is <br /> I! Fee Is Due:'❑ ANNUALLY ❑ PER UNIT- ❑ PER SITE ❑ EACH ❑ January S &Received By'January 31' ❑ July 1 &Received By July 31 <br />! v * REMIT <br /> BILLING REMITTANCE :$ <br /> _ BASE -EXPLANATION - • _ AMOUNT DUE CHECKED <br /> •1. - DATE -DATE- 'REMITTED AMOUNT <br /> fFEE D E S <br /> r LESS <br /> PRORATION -' "- - - - O�LIq.t1�!. - 7'� i,u -[a.? t jf- <br /> PLUS - -� - <br /> PENALTY /f <br /> i <br /> OTHER <br /> k _ <br /> -OTHER <br /> Received by Dife Receip[ o. Permit No. Issuance Date filed Delivered <br /> y <br /> 1601 E.HAZELTQN AV <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES ax 2009 STOCKTON,CA95201- <br />