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APPLICATION <br /> r Non-Transierable,Revocable,and Suspendabl._ <br /> t ENVIRONMENTAL HEALTH PERMIT SEPTAGF <br /> LIQUID WASTE <br /> Fr Application is lwrebyw made to arty on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA ` Address 125 ' <br /> cOwner Address �----�— <br /> Firm Partners, Addresses and Telephone Numbers^ <br /> Business Telephone No. ?2z— _ Emergency Telephone No. ' <br /> kkk� Contractor Licence No. <br /> a Applicants Name (Print) 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 /> Seriall No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> F" <br /> Equipment Parking Address <br /> F, <br /> 13 Equipment <br /> YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> ' <br /> F,:`3, 11PERCOLATION TEST <br /> R.S.or R.C.E. Name �^ R.S. or R.C.E.No. <br /> Test Lo�dtion Test Date/Time W <br /> 4. SANITATION PERMIT <br /> 'Job Address/Locate n t *7 3-3 .. a <br /> Ow er <br /> 3 = Address ' <br /> PEPTICC TANK ❑ CESSPOOL LEACHING FIELDPAGE'PIT ❑ PACKAGE;PLANT <br /> PLAY PERMANENT ❑ TEMPORARY ❑ NEW - =REPAIR ❑ OTHER,' . <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> tType Construction Disposal Site <br /> II �No. of Units Equipment Storage/Cleaning Locations) . <br /> �6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 s <br /> Operator Name ere-Certified <br /> PlantLocation <br /> 'Plant Capacity No. Units Served If <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,006Sq. Ft., ❑ More Than 1,000`Sq. Ft.' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. E <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 'uiations of the San aaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> ' r f <br /> F FOR DEPARTMENT�USE O <br /> Fee IS Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE 13 EACH ` ary'14 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING RE ANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> FDATE ATE REMITTED AMOUNT <br /> FEE y� <br /> LESS <br /> PRORATION <br /> 7 _ PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � S,�30,S y J? � <br /> Received by Date Recei No. Permit No. Is uance Date Mailed Delivered - <br /> f APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISE?IV`I,CES� 160)E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA"95201 - <br />