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t ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. N <br /> ` = APPLICATION <br /> (For Non-Transferable,Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t `f'C N• _ZLLG �.p,q:,J k�� .. ..� LIQUID WASTE <br /> t Z71 <br /> Application I mad carrLon business in the jurisdictional area of the San Joaquin Local Health D' tr'ct <br /> H Business Na a (DBA) - tJ F r <br /> _ _Address <br /> a Owner <br /> Address <br /> Firm Partners, Addresses and Telephone Nu .. ers <br /> CL <br /> Business Telephone No. r Emergency Telephone No, <br /> Contractor Licence No. fr <br /> Applicants Name (Print) 4 C' Title-_4 S' 1' Date r <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For Jdly 1, June 30, 19 _ Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. <br /> CAL. License Renewal No. <br /> Capacity Gal:',Weights & Measures No. <br /> Equipment,Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July i, June 30, 19 . k <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name <br /> R.S. or R.C:E. No. - <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT �� � <br /> Job Address/Location /U Il/CK✓ <br /> O ner 1(1�,1�r' f�l.�9t�+ fix Address <br /> EPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 4AEERMANENT ❑ TEMPORARY EW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction - - Disposal Site <br /> No. of Units <br /> Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity I No. Units Served r <br /> 7. ❑ LAUNDRY For'July 1, -June 30, 19 1 <br /> SIZE: ❑ Less Than 1,000 Sq: Ft., ❑IMore Than 1,000 Sq. Ft. " <br /> '❑ DRY CLEANING;Chemicals Used/Amount/Mo. <br /> A <br /> f ' h <br /> he work willbb done in accordance with San Joaquin County <br /> 1 hereby certify that I have prepa t is a plicand that td <br /> ordinances, state laws, and rule re atio oUWeSanJQ6qUin cal Health District. <br /> APPLICANT'S SIGNATURE X <br /> a <br /> 4 FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH _ ❑ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ - - REMIT <br /> - - DATE- DATE- REMITTED AMOUNT DUE CHECKED <br /> AMOUNT F <br /> FEE <br /> LESS <br /> PRORATION - - <br /> PLUS <br /> PENALTY <br /> J OTHER <br /> ATHER <br /> / 643-3 . <br /> Received by Date 'Receipt No. Permit No., Issuanc Datel Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952015 <br />