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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> �r Non-Transferable, Revocable,and Suspendatr,o SEPTAGE <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is erebyemade to carry on business in the j irisAction area of the San Joaquin Local Health D' tact <br /> ,,;Business Name (DBA) oe' - Address <br /> -9 Owner Address - —�---- <br /> J Firm Partners, Addresses and Telephone NumbersCL <br /> cL Business Telephone No. 3(nLC9i0 S Emergency Telephone No. <br /> j Contractor Licence No. :—I G t <br /> Applicants Name (Print) Title �kd-d=zo Date -3 Y� rr <br /> Please check Applicable Category(1-7)and Fill in the Required Information —r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> 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 L ation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location W <br /> Owner rAddress D 43,,+ y `�7 ." <br /> 9--SEPTIC TANK ESSP OL ❑ LEACHING FIELD ;a;;SSS, PAGE PIT ,❑, PKAGE PLANT <br /> 9 PERMANENT ❑ TEMPORARY ❑ NEW L'3'14FIR I OTHER u r /_�,,� uj /►'�q <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 /> Operator Name Where Certified <br /> Plant Location _ <br /> oc <br /> Plant Capacity No. Units Served 1 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ec <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 regulations of an <br /> 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> /.� C AMOUNT <br /> FEE F� s 1VJ— <br /> LESS 2 j Ma `, <br /> PRORATION �1 <br /> tic F�) <br /> PLUS <br /> PENALTYOAOL� <br /> OTHER �� Q <br /> OTHER <br /> to a-33 � <br /> Received by Date Receipt No. Permit No. lssuancbate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> KP<iP(M1d & i.1- r <br />