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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Slgn The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ereby made o carry on business in the jurisdictional area of the S Joaquin Local Health Dist <br /> Business Name A) r�f___ �"C Address c 21 t" 76 7 <br /> rs <br /> Owner- - -- <br /> r __ Address -� '� ---- <br /> Firm Partners, Addresses and Telephone Numbers -- -- a! <br /> Business Telephone No. <br /> IF- -.r/0 ` _ ------ Emergency Telephone No. --- C <br /> i Contractor Licence No. Z Z - — Lk <br /> L Applicants Name (Print) ► Tide — Date <br /> 6 <br /> Please check AppNoabk Category(1-1)and FIII In the Requ red Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July f,_ June 30, 19 Disposal Sites <br /> Description(MakO/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 �y — tddresX_;_!_ <br /> �Job Address/Locati L 44`r ,r, � 4L <br /> O er A(' __ _ - <br /> V PTIC TANK ❑ CESSPOOL VN <br /> CHING FIELD ��SEFPAGE PIT ❑ OTHER <br /> GE PLANT <br /> l� PERMANENT ❑ TEMPORARY W ❑ REPAIR <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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name _- <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. Ff., ❑ More Then 1,000 Sq. Ft.114. <br /> — - <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. -- -- — -- <br /> I hereby certify that I have prepated this application and that the work will be done i7� rdance with San Joaquin County <br /> ordinances, state laws, and rules nd regulation s of r a Joaquin Local Health Di�ic <br /> APPLICANT'S SIGNATURE X --- <br /> FOR DEPARTMENT US L <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH nusry 1 6 Received By January 31 ❑ July 1 8 Received By July 31 <br /> -- - — - -- REMIT <br /> BASE EXPLANATION BILLING MANCE $ AMOUNT DUE CHECKED <br /> DATE s ATE REMITTED AMOUNT <br /> FEE -- <br /> LESS <br /> PRORATION --- <br /> PLUS <br /> PENALTY _ <br /> OTHER <br /> OTHER19 ILI <br /> r <br /> r <br /> Dy ------ Oate Receipt n Permit No Issuance Dale Delivered <br /> APPLICANT—RETURN ALL cOPlt:a t0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.9o:2009 STOCKTON,CA 95201 — <br />