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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. , <br /> APPLICATION <br /> F (For Non-Transferable, Revocable,and Suspendabie) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE - <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) ji <br /> _ "3ki '►1<` ]j j . 1`_. +� Address :�r-' Z' - <br /> I-a Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No.. -` � I Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) r7 ,,r'r' •� ,ih `7 Title -'�� "t i j�i Date <br /> a <br /> FrPlease,check Applicable Category (1-7)and Fill in the Required Information r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July-i, m June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. 1.4cense-No. CAL. License Renewal No. <br /> Capacity - w ,GaI; Weights&Measures <br /> lEquipment Parking Address <br /> F2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> FNo. of Vehicles Stored <br /> .No. of Chemical Toilets Stored = <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name <br /> R.S:'or R.C.E. No. <br /> Test Location Test Date/Time,` <br /> 4. SANITATION PERMIT <br /> Job Address/Location _ _ ' e ' <br /> F", <br /> Ower ` -1 1. e <br /> 4:' . Address �".� <br /> 0 SEPTIC TANK ❑ CESSPOOL ®LEACHING FIELD. SEEPAGE PIT Q..PAbKAGE PLANT <br /> E'PERMANENT ❑ TEMPORARY O NEW ..`r ❑ REPAIR ❑ OTHER <br /> i 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 C <br /> Type Construction ~Disposal Site <br /> No. of Units Equipmerif'8torage/Cleaning Location(s) (j <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,--June 30, 19 T! <br /> r C <br /> `Operator Name -Where Certified <br /> Plant Location `1 <br /> No.'l1n <br /> Units Served Plant Capacity <br /> 0 <br /> 7. 11 LAUNDRY For July 1,-June 30, 19 <br /> F ❑ . Ft. <br /> SIZE: 11 Less Than 1,000 Sq. Ft., More Than 1,000 Sq <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Y. <br /> I I hereby certify that l pav prepared this appl catioiT`and that the.w8rk yd�f be done ii 'accordance with San Joaquin County <br /> ordinances, state lawt an r" es and re iattgfls of kh an Jo Local Health District. <br /> 44 <br /> APPLICANT'S SIGNATURE') , <br /> FOR DEPARTMENT U Or,ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER 1fN1T ❑ PER SITE 1 f;EACH (� January 1 &Received By January 31 ❑ July 1 8 Received By July 3i <br /> REMIT <br /> F, BASE EXPLANATION <br /> BILLING REMITTANCE AMOUNT-DUE CHECKED <br /> N DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> r <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER " <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issua7ricel D e IMailed Delivered <br /> " -_J1 . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />