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Applications Wilt Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. t <br /> APPLICATION <br /> .i (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Appl icati n ' hereb ma a ry on busin s in the jurisdictional area of t San Joa q in Local H at Distrt <br /> NBusiness Name (DBA) - Address <br /> aOwner . Address <br /> Firm Partners, Addresses and Telephone Numbers f <br /> IL Business Telephone No, - f # _ Emergency Telephone-No. <br /> � <br /> Contractor Licence No. ate <br /> D <br /> LApplicants Name (Print) "V Title �I <br /> Please check Applicable Category-(1-7)and Fill in the Required information �r <br /> 1. -❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites y <br /> Description(Make/Yr., Color) <br /> Serial No. <br /> CAL. License No. CAL. License Renewal No. -�'.''�. <br /> _f <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> :2. 11 PUMPER YARD �. <br /> For July 1, June 30, 19 ; <br /> No. of Vehicles Stored {., 7 <br /> No. of Chemical Toilets Stored t <br /> 3. ❑ PERCOLATION TEST <br /> R.S..or,R.C.E: No.—ti--t -1 <br /> R.S. or R.C.E. Name 4 "" - <br /> Test Location ) Test Date/Time <br /> 4.,X SANITATION PERMIT l <br /> Job Address/Location Y ' <br /> Owner e--"T Address y. <br /> �YSEPTiC TANK ❑ CESSPOOL{ LEACHING FIELD SEEPAGE'PIT"A-❑'PACKAGE PLANT <br /> -1R1 PERMANENT El TEMPORAY R-NEW ❑ REPAIR i. <br /> ❑ OTHER + <br /> 5. ❑ CHEMICAL TOILETS For July i, -June 30, 19 <br /> Type Construction Disposal Site <br />` 5..." <br /> No. of Units Equipment Storage/Cleaning Location{ )' <br /> �. t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1.,.-June 30,099 <br /> Operator Name e " 'n 'Y ) Where Certified <br /> Plant Location _ , ;V, <br /> Plant Capacity No. Units_SeryeB` - <br /> -' <br /> 7.' ❑ LAUNDRY + For July 1, -June 30, 19 4 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft' y <br /> .❑ DRY CLEANING,Chemicals Used/Amount/Mo. i <br /> f <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 a ationstf-g;6nJoaquin Local Health District. <br /> APPLICANT'S SIGNATURE X $ <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS DUB: ❑ ANNUAL ❑ R UN { ❑ PER-SITE f ❑ EACH ❑ January 1 &Received 8y January 31' ❑ July 1 SfReceived By July 31 <br /> I __ +� ��j REMIT <br /> -k •�- "ac ' --BILLING REMITTANCE $ AMOUNT DUE � CHECKED <br /> 8A5E E LAIHATION AMOUNT <br /> T DATE DATE REMITTED <br /> FEE <br /> LESS ,! 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER t <br /> OTHER <br /> ..)` Perrnit No--- as ancc ate Mailed, D <br /> Received by Date e ivered <br /> Receipt No. ,�; ,,..yam <br /> HAZP.O.Bay 2009 STOOKTON,CA 950 <br /> APPLICANT—RETURN AIL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. ELT <br />