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Applications Will Be Processed When Submitted Properly Completed. Be Sure 10 519n Ine Nppncaiu 1. <br /> APPLICATION <br /> for Non-Transferable, Revocable, and Suspendat�.i SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> _ Application Is ereby made to carry on/b mess in the jurisdictional area of the Saa Joaquin Local Health District <br /> Business Name (DBA ��XIG�/" Address /' ��� ��� <br /> Owner f C oP Address �`y l02 f A.CF1G�1/1 <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. ccm <br /> c Applicants Name (Print) Title z 4 -at Date <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) O <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 Gal.,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. Name R.S. or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location AV j5g t�XrX'7­ <br /> Ow o Address ,��7.�'/✓I c4 6^ <br /> 10 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT. <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER _ - <br />( 5. ❑ CHEMICAL TOILETS For July 1,-June 30,19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 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 - - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/MO. <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 r ulatio s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Z�dlg!5 . <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is DUO: ❑ ANNUALLY PER UNIT ❑ PER SITE - ❑ EACH ❑-January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION DATE 1 DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER �x <br /> OTHER <br /> • 0 $34� 1 n 1�-I"Sa <br /> Received by Date Receipt No. Permit No. I me Date Mailed Delivered <br /> APPLICANT—RETURN ALLCOPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.NAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 952 <br />