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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 /> Applica'on is hereby made to carry on business in the jurisdictional area of the S n oaquin Local Health Dist' <br /> y Business Name (DBA) - 1� L t L� �slS�b � Address ` � kx <br /> �� - <br /> aOwner � LIQ.A L 1 I IC L L-_.. _: Address <br /> 0 Firm Partners, Addresses an Telephone Numbers n <br /> aBusiness Telephone No. _ Emergency Telephone No. <br /> Contractor Licence No.-135' <br /> o. t y ` y <br /> L Applicants Name (Print). Titlef' t-ei��Date - <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19� Disposal Sites t <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Llcense Renewal No. <br /> CapacityGal:-, 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. <br /> R.S. or R.C.E.-Namea R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4, ❑ SANITATION%PER i _ rw ----�• �— --- 6 - ,_ M <br /> Job Address/LocationiS <br /> Owner � �l.I D F kv iN V Address ' <br /> �SEPTIC,TANK I❑•CESSPOOL t � LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENTS "❑ TEMPORARY NEW r ❑ REPAIR --❑.,OTHER ' <br /> 3. 0 CHEMfCAL'TOILETS For July 1, -June 30, 19 <br /> r <br /> Type Construction f �� ; Disposal Site .:No. of Units •e Equipment Storage/Cleaning Location(s) 91 " <br /> 6.: ❑ PACKAGE TREATMENTPPLANT For July`1"=June 30,-19 <br /> Operator Name ti " �' '� Where Certified <br /> Plant Location' '` ' - <br /> Plant Capacity T 5 ,N* I . Ir.- No. Units Served nn�� <br /> 7. ❑ LAUNDRY For July 1, -June'3Q 19 <br /> r <br /> -SIZE: ❑ Less Than 1,000 Sq. Ft.,, '[]..More Than'1,000 Sq. <br /> ❑'DRY CLEANING, Chemicals Used/Amount/Mb. <br /> I hereby certify' that`I ave prepared this^application and that the work will be done in accordance with San Joaquin County <br /> ordinances, slat laws, rules a d reMYolthLean Joaquin L cal Health District. <br /> APPLICANT'S SIGNATURE X <br /> di <br /> w <br /> i r <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY{"- ❑ PER UNITf ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE ?EXPLANATIOPt ' BILLING REMITTANCE AMOUNT DUE CHECKED' <br /> ' - DATE_._ ...••DATE RENYTTE AMOUNT <br /> 17V @q <br /> FEE <br /> N z; <br /> LESS <br /> I PRORATIONPLUS <br /> f' . <br /> PENALTY <br /> �. OTHER <br /> OTHER r <br /> l <br /> Received.by to - Receipt No. -. y Permit No-' I issuanc Date Mailed Delivered. <br /> t <br /> APPLICANT-RET ALL COP 5 TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 E.HAZELTON AVE.,P.O.Bar 2009 STOCKTON,CA 95201 <br /> 1 / <br />