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-L - G J Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 0o t� APPLTICATION <br /> ^ <br /> 02 (For Non-Transferable, Revocable, and Suspendable) SEPTAGE �' U <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) ��,/ G�{'1/�3 Address/-3%/4 <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Prim O / Title Date <br /> Please check Applicable Category (1-7) and Fill in th Required Information <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 J <br /> 2. ❑ PUMPER YARD / C1 <br /> For July 1, June 30, 19 I l <br /> No. of Vehicles Stored <br /> o. of Chemical Toilets Stored <br /> 3.,, ERCOLATION TEST <br /> S. or R.C.E. Name 7ODU ,GLd1 ) ��r,tel R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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 /> Plant Capacity__ No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> [],PRY CLEANING, Chemicals Used/Amount/Mo. - <br /> OTAOwrrflrprt:Ceflgp,�,���n2 . ;,t�r9 � <br /> in suc,"mann%.;t0 berm s *s.'1 hs follo of <br /> Oor,tracta;s f,r; J i ' r nrrnftheworp,fOrWhichthISpermitisiss'ed,tshstlnotem to a r <br /> ^J or srrb c RUac,^ P y �l pers'7 <br /> �i9jJy,iiefSOnS Sutli„ta t0�:O�K.i.aFt S Cuit;pciL.,;i), :s ut CLw�;�ril... .. <br /> ce' i�,. t,e M.:JI 2;1ce Of the work for which Iti:,pern:a is iS�ue I c; <br /> I hereby certify that I have prepared this a Ii tion that h work will be done in accordance with San Joaquin �ourity <br /> ordinances, state laws, a ules and reg ti s of t an J uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> � T <br /> FOR DEPARTMENT USE ONLY ��� 3{ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATEn REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _. <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> fy) 010 <br /> Received by Date Receipt No. Per No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/h'9Trl 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />