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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> . rt (For Non-Transferable, Revocable,and Suspendable) I SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl icatio is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,-Business Name (DBA) .�p�� >C "� 5��•��'« ��`= Address E <br /> i Owner w Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> E Business Telephone No. <br /> 7s'S Emergency Telephone No.. 7"�' a ale <br /> Contractor Licence No. jj p <br /> Applicants Name (Print) �a � .9 Ae Title r Date <br /> Please check Applicable Category(1-7)and Fill in the 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) I <br /> Serial No. ) CAL. License No. CAL. License Rerrewal 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 /> J/1Ji� l� I �d,��ld�/LIL✓�!r/'' i <br /> Job Address/Location���� 4tf"WP <br /> Owner �� '_e Address <br /> P SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ® SEEPAGE PIT PACKAGE PLANT <br /> IPO PERMANENT ❑ TEMPORARY 19 NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 y <br /> Type,Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) f <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 /> IIS_ SIZE: ❑ Less Than 1,000 Sq. Ft., El More Than 1,000 Sq. Ft. }} <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 1, <br /> i <br /> i <br /> K <br /> } <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, d rules and regulations of the San Joaquin Local Health District. <br /> 111 <br /> APPLICANT'SSIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 11January 1 &Received By January 31 [I July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE - $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED 5 AMOUNT <br /> FEE " <br /> LESS j <br /> PRORATION <br /> PLUS Vere uI by�hahc <br /> PENALTY <br /> OTHER Y SYS W <br /> OTHER <br /> a <br /> Received by Y e Date Receipt No, Permit No. I sua ce Date Mailed Delivered_ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95.201 <br />