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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I APPLICATION <br /> 4 (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is reb made to carry n busines n the jurisdictional area of t San oaquln Lo al Health �l trl r <br /> m Business Name (DBA) � ier51� S/�- Address�O ly',Q -Si •Y. ._ � �-0/ <br /> z Owner f Address - <br /> a <br /> J Firm Partners, Addresses and'Te``le'p o —!96hne Numbers <br /> aBusiness Telephone No- 1 Y 9 — �6 7 Emergency Telephone No. Y <br /> _J Contractor Licence No. , .~: Z - <br /> Applicants Title �� Date Z <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J <br /> For July 1, June 30, 19 a Disposal Sites <br /> Description(Make/Yr:, Color) <br /> Serial No. ," t CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.;Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD - <br /> }.. .� J�• <br /> For July i, 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. Name R.S. or R.C.E. No. <br /> Tescation Test Date/Time <br /> 4. WISANITATION PERMIT Mgt <br /> Job Address/Location -6, vTo Al <br /> Lnot <br /> Owner R Address F <br /> SEPTIC TANK ❑ CESSPOOL << LEACHING FIELD .SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY . NEW `-'� ❑ REPAIR :❑ -OTHER <br /> 5. ❑ CHE=MICAL TOILETS For July 1, -June 30, 19 ,' }` If <br /> Type Construction IDisposal Site <br /> -4. <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATM ENT PLANT For July 11!' Uunb`30, 19 <br /> Operator Name Where Certified `� <br /> Plant Location - <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 •, sS _ .. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. 4 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 5 <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 a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 47 <br /> a- FOR DEPARTMENT-tt;SE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By olfuaryA ❑ Jul Received By Jury 31 l <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ UNT DUE CHECKED <br /> - _ - - DATE DATE REMIT - -AMOUNT49 L <br /> - <br /> FEE <br /> r <br /> LESS t - <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER g <br /> OTHER _ <br /> Received by i Date Receipt No. Permit No tssuanc D Mailed elivered <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1&01 E.HAZELTON A .Box 2009 STOCKTON,CA 95201 , <br />