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Applications WillBe Processed When Submitted Properly Completed. Be Sure To Sign TheApplication ;r <br /> APPLICXTIOW <br /> (For Non-Transferable,Revocable, and Suspendable) / SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT (/ <br /> LIQUID WASTE <br /> Application Is hereby made to carry on businesi ii he jurisdictional area of the S�j Joaquin Local Health District .,i <br /> + e++,/S Address I ! �+ !' ZO <br /> OF Business Name (DBA)_J2 � � - ' <br /> a Owner - � :: . '. �' <br /> Address <br /> J Firm Partners, Addresses and Tele hone Numbers 1 <br /> CL a Business Telephone No.. . © Emergency Telephone No... <br /> �Contractor Licence No. e� Z�*d <br /> Applicants Name (Print) Title : Date <br /> Please check Applicable Category(1-7) and Fill in the Require nfarmalion <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Fo"r July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) - v� <br /> Serial No. CAL. License No. CAL. License•Renewal <br /> Capacity Gal., Weights & Measures No. , ^, <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD s Cc <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Nam_a R.S. or R.C.E. No. 1 <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT 00 ZO /�-ePm <br /> i <br /> / <br /> Job Addres ocation j <br /> Owner ':'_ Address <br /> SEPTIC TAN ❑CES5P00L "`A—LEACHING FIELD— -06-SEEPAGE PIT—GI—PACKAGE-PLANT <br /> ❑ PERMANENTS© TEMPORARY NEW El REPAIR ❑ OTHER <br /> 5. 1:1 CHEMICAL TOILETS For July 1'-June 30, 19- <br /> Type <br /> 0, 19Type Construction. Disposal.'Site��--t# ? t A r1 <br /> No. of Units Equipment Storage/Cleaning Location(s) } <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> x <br /> Operator Name Where Certified <br /> Plant Location F� <br /> Plant Capacity �^No. Units Served t <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 lased/Amount/Mo. <br /> Homeowners.e-zencedngant'nsignaturece:ririesthe faticwln�."1cerii; ?;rtheGetcr~artse�f.lelvart4-f�rr.h!eh-tfiiapermit isissued,!shalt not employ anyperson <br /> in such manner u J}3 :o;re subidc l i a'C-'r'man's cempenspt c r ! <br /> Corttreetor'c e.., �• s�k_-o -�-r�r. _:� �' ;,.c pari , r�a;r�.o:tix:var�i0r!vtic this perinit is issued.l shall <br /> 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 nd re_gul ions o the aquin Loca lih trict. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPART.MENT,USE ONLY <br /> _ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑OJuly 1 &Received By July 31 <br /> - REMIT <br /> BILLING REI4AITTANCE., $: a'" AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> DATE - "DATE REMITTEb. ii - AMOUNT <br /> FEE <br /> i <br /> LESSC <br /> [ PRORATION r <br /> PLUS <br /> r PENALTY <br /> i OTHER <br /> OTHER421 <br /> - 13 - <br /> Received by Date Receipt No. 'Permit�' ssuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM VI S` 1601 E.HAZELTON AVE.,P.O.Box 2409 STOCKTON,CA 95201 <br /> i � <br />