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APPLICATION <br /> Non-Transferable,,Revocable,and Suspendablr SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE , I. <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> uri Business Name (DBA) /9-_Gd;kA_> �. Wdeb Address I4;!�4 WWA! z z_—� <br /> z Owner .Address <br /> J Firm Partners, Addresses and Telephone Numbers ? 1 <br /> aBusiness Telephone No._ �"� -3�7 _ Emergency Telephone No. <br /> -J Contractor Licence No. <br /> LApplicants Name(Print) Title- ��"�� Date <br /> Please check Applicable Category(1-T)and Fill in the Required Information --C <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites. n <br /> I� 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 &, 30 �• f;y�9 � � - ,� <br /> Owner Address l � <br /> SEPTIC TANK ❑ CESSPOOL . LEACHING FIELD SEEPAGE PIT ❑`PACKAGE PLANT (/11 <br /> ❑ .PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑-`OTHER d <br /> 5. 0 CHEMICAL TOILETS For July 1, June 30, 19 <br /> Type Construction " Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) ( t <br /> Ti. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 1. ❑ LAUNDRY For July 1,-June.30, 19 <br /> 'SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ <br /> DRY i Cemic is Used/AmOUrIVMo <br /> rr CRRft a• <br /> fn Su h <br /> C marnsrastot� <br /> . .,.. , <br /> �1T�•f n❑,� .,C.. f, „Ja<i,..6h i <u 1 i i t .. . t ' I c erPloyCont`actor's eaa rr <br /> emi ,1 <br /> rW 1" : s <br /> IN�.iO C::ur•,..,,ti d., r, � ',n ..i-:j i.,.SSU80.. d'.: <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 regulatio San Joaquin Local Health'District.' <br /> APPLICANT'S SIGNATURE <br /> (� _(DI . <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ,❑ PERUNIT _ ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 .❑ July 1 &Received By Juiy.31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE ' EXPLANATION AMOUNT DUE CHECKED <br /> DATE - DATE- REMITTED -AMOUN <br /> CO <br /> FEE �I. .-: .� <br /> LESS <br /> PRORATION '. <br /> PLUS I <br /> PENALTY - <br /> OTHER �i I <br /> -i <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Difivered <br /> APPLICANT—RETURN ALL'COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.MAZELTON AVE., .O..Box 2009 STOCKTON,CA 95201 <br />