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/ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPUCAT1414 �!I <br /> sr„ (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ,.I LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local,Heallh District. <br /> y Business Name(DBA) 'Gdf <br /> aOwner.,.,.,,, -, Address <br /> f Firm Partners,Addresses and Telephone Numbers <br /> E Business Telephone No. A�_3 7�� _ - Emergency Telephone No. R r <br /> fa Contractor Licence No. ,-A]G <br /> LApplicants Name(Print) 54&yz! Title � Date <br /> Please check Applicable Category(1-7)and fill In the Required-Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLEI v 42 - O <br /> For July 1, .. June 30, 19 - Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. I CAL.License No. _- CAL. License Renewal No. <br /> Capacity Gal.,Weights A 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.G.E.Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Adc6ss/Location &zmg <br /> Owner Address ,- <br /> 4 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT SIU <br /> ❑,.PERMANENT ❑ TEMPORARY ❑'NEW REPAIR ❑ OTHER t� <br /> ` <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 y <br /> Type Construction Disposal Site i <br /> No-of Units Equipment Storage/Cleaning Location(,) + <br /> 5. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location i r <br /> Plant Capacity f No. Units Served r.fl <br /> 7, ❑ LAUNDRY . For July 1,-June 30, 19 . 7 """1 r'- ' i t <br /> i . <br /> SIZE: ❑ Less Than 1,000 Sq- Ft., Elan Than 7,000 5q, Ft. It <br /> ❑ DRY Used/P mounVMo. <br /> conse <br /> in such manner as to bac cr:cl hJert!o 3, `,, , r :c" :yc t. for irt;;;! fy1, r^1f1 i i <br /> 7 i55L_¢ �s`aif nc:ompl4y an er58ri <br /> ontrocCor•� ;3irin� n, �:¢�-c.�art:cciinl rr!r[i: s; � ,s., ••^.I. A YP <br /> employ pe1 <br /> s41 <br /> s cL�1^_a.3:YOrismari s cafi <br /> :pcn�ntic;tiarsnfC_...rni .' Scc'.rliG I i .p;lmitis"sssuetl.lshall <br /> 1 ` <br /> I hereby certify that I have prepared this application and that the work will be done 10 accordance with San Joaquin County <br /> ordinances,state laws, and rules and regulatio - San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X _ <br /> —« 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 /> L =BILLING REMITTANCE $ . REMIT <br /> t <br /> BASE-"' - EXPLANATION AMOUNT DUE CHECKED <br /> DATE - - DATE REMITTED <br /> AMOUNT/ <br /> FEE. <br /> LESS " <br /> PRORATION i .N 1 <br /> PLUS - • . , ,! r <br /> PE NALTV �} • » <br /> . OTHER, - <br /> , <br /> OTHER ; <br /> Rete+ved by Cate Receipi No. Permit No. Issuance Date ailed DOW red ; + <br /> APPLICANT—RETURN ALL COPIES TO: ' ENVIRONMENTAL HEALTH PERMITISERVICES 1601 F_HAZELTON AVE., .Box 2009 STOCKTON,CA 94201 ' <br />