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Applications Will Be Processed When SubmittedProperly GomP1ll -�• - <br /> APPLICATION -� <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> X. ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicat' n is hereby made to carry on business in the jurisdictional area of the San Jostrict <br /> �aqu'I{�n Local H �� � ` <br /> Address <br /> FBusiness Name (DBA) Address <br /> z Owner <br /> 4 <br /> Firm Partners, Addresses an -TelephRI one Numbers Emergency Telephone No. <br /> aBusiness Telephone No. 3� <br /> _JContractor Licence No. Title $ Date <br /> Applicants Name (Print) f� . <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) V . <br /> June 30, 19 Disposal Sites <br /> For July 1, V <br /> Description(Make/Yr., Color) CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Gat.,Weights &Measures No. <br /> Capacity <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, 13 PERCOLATION TESTR.S. or R.G.E. No <br /> R.S.or R.C.E. Name `Test Date/Time <br /> Test Location ` <br /> 4. Rf SANITATION PERMITItAt <br /> f� Ei(/ �iT�✓ ' <br /> Job Address/Location U Q t `j crC d8 <br /> Owner �4� � 5 Address ❑ PACKAGE PLANT <br /> ❑ <br /> SEPTIC TANK ❑ CESSPOOL $LEACHING FIELD 0 SEEPAGE PIT ❑ OTHER <br /> PERMANENT <br /> C3 TEMPORARY 156 \-.NEW t it a <br /> �-�+ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 1Dlsposal Site �\ <br /> Type Construction 1 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name 4 t <br /> Plant Location No, Units Served <br /> Plant Capacity �s <br /> 7. 11 LAUNDRY For July 1, -June 30, i9 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. � # <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. �4 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance Vill San-Joaquin County <br /> ordinances, state laws, an les and regulations of the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE { %��' �:� 1 <br /> FOR DI=PARTMENT USE ONLY <br /> 31 <br /> Fee S Due' ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 July 1 &ReceiveRdJuly <br /> EMIT <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED V AMOUNT <br /> FEE rY <br /> LESS <br /> PRORATION 10 _ <br /> PLUS i <br /> PENALTY <br /> i <br /> � ttt <br /> OTHER a <br /> OTHER <br /> Issuance Date Mailed Delivered ' <br /> Receipt Permit No. - <br /> Received bNo.y Date 1801 E.HAZELTON AVE.,P.D.Boa 2409 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> c <br />