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APPLICATION ' <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> F Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ;;'uusiness Name (DBA) /5401 Z� Address -5L; C <br /> z Owner Address <br /> affirm Partners, Addresses and Telephone Numbers <br /> n ,tusiness Telephone No. 1i�� -397 Emergency Telephone No. <br /> Contractor Licence No. Z ; <br /> a(^ ppiicants Name (Print) ja," 7 li. "D __. - Title. Date <br /> lease check Applicable Category (1-7)and Fill in the Required Information `L <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> or July 1, June 30, 19 Disposal Sites <br /> )ascription(Make/Yr., Color) <br />' aerial No. CAL. License No. CAL. License Renewal No. <br /> i <br /> Capacity Gal.,Weights&Measures No. <br /> [quipment Parking Address <br /> . ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> r4o.of Vehicles Stored <br /> o. of Chemical Toilets Stored <br /> 1. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.G.E.No. <br /> Ffest Location Test Date/Time <br /> L 11 SANITATION PERMIT <br /> Job Address/Location <br /> F� <br /> wner �1 l . �+srt n, offs Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT CN <br /> —❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR . ❑ OTHER QI <br /> 5. ❑ CHEMICAL TOILETS For July 1,=June 30, 19 <br /> Type-Construction Disposal Site <br /> III <br /> F.No. of Units Equipment Storage/Cleaning Location(s) <br /> S. U PACKAGE TREATMENT"PLANT For July 1,-June 30, 19 <br /> Dperator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. 11 LAUNDRY For July 1.,-June 30, 19 <br /> FSIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> -'❑ DRY rs <br /> rF�dVv 'C emtc'I Used/AmountlMo <br /> cr q�n 2n� <br /> tich 111art0EI'dS ntsa.^.4nr's ii�rirn t+� ::;}I-. .,• i i . <br /> �I empioy perspr. p`. .l <br /> 1 hereby certify that I i have prepared this application and that the work"will be-done in accordance with San Jdaquin County <br /> fordinances, state laws, and rules and regulatio San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> F4 FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY. :❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE" ' EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT/ <br /> 6� <br /> FEE <br /> LESS £j <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER .y <br /> Received by Date Receipt No. Permit No Issuance Date Mailedelivered <br /> GGG APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE., .O.Box 2009 STOCKTON,CA 95201. <br /> I <br />