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Applications Will Be Processed When Submitted ProperlyCompleted. BeSureToSign I!neAppucauon <br /> h APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> /y ��ENVIRONMENTAL HEALTH PERMIT �� Z <br /> Ai � ~' K LIQUID WASTE <br /> A licati y <br /> is hereby ingde to ceVy on i busine in the jurisdictional area of the San Joaquin Local ealth District/ <br /> rn Business Name (DBA) �el C/ {/��G C sit/ST ,. Address ' y •' � �fl� t r �� <br /> aOwner__. _ -- Address <br /> Firm Partners, Addresses an elephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Prin 'z �>! / _ Title _ 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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No.---- <br /> Capacity <br /> o. -Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address— <br /> 2. ❑ PUMPER YARD � <br /> _ CZ <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored —G <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. _ <br /> Test Location Test Date/Time <br /> 4. ®S�ITATiON PERMI f/ ---- % <br /> Job Addr s/Location 7z-x , • Z/R/be'l� <br /> Owner Al Address - <br /> f SEPTIC TANK CESSPOOL J2 BLEACHING FIELD EI SEEPAGE PIT ❑ PACKAGE PLANT <br /> P RMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Y <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) 5 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> i Operator Name Where Certified <br /> Plant Location -- } <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 _ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑rDRY CLEANING, Chemicals Used/Amount/Mo. <br /> 20 4— ...aa� <br /> hereby certify that I have prepa d this application and the work will be done in accordance with San Joaquin County <br /> r ordinances, state laws, and r e and regulationsrat nJ a oin,Local Health istrict. <br /> APPLICANT'S SIGNATU <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: Cl ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & ceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BAS£ EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE TV <br /> — <br /> LESS <br /> PRORATION t <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permil No. issuance Dal Mailed elivered / <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTO IA O.Box 2009 STOCKTON,CA 95201 �/ <br />