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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheAPPIICalon. <br /> µ APPLICATION <br /> (For Non-Transferable, Revocable,'and Suspendable) j SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT r <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District - <br /> F Business Name (DBA).DAFXe�� ���= �'� .' Address Z <br /> { a Owner F .;� Address. - - <br /> j Firm Partners, Addresses and Telephone Numbers <br /> aEmergency Telephone.No. <br /> a Business Telephone No. , <br /> Contractor Licence No. <br /> Date <br /> :;., <br /> LApplicants Name (Print) �I gaMS Title E <br /> " <br /> Please check Applicable Category (1-7)and Fill In the Required.Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> i _ . Disposal Sites - <br /> For July 1, June 30, 19 Dis p <br /> E <br /> Description(Make/Yr., Color) i <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 .� s <br /> 3. 0 PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time L <br /> 4.XSANITATION PERMIT <br /> Job Address Location 3� S \ <br /> Address _ <br /> Owner G <br /> Tc�SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT 0 PACKAGE PLANT <br /> ! tai PERMANENT ❑ TEMPORARY ❑ NEW« s WREPAIR ❑ OTHER {� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 u <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> .6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 3019 E <br /> I'- F - Where Certified <br /> pop^ Operator Name - # <br /> ` E <br /> t; Plant Location - r <br /> } Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY" For July 1, ryJune 30, 19 <br /> SIZE:, I] Less-Than 1.,000 Sq. Ft:, ❑ More Than 1,000 Sq. Ft t b y _ - <br /> � ��' ewor arw rc i ispermitisissul�,IshallnotempfoyattypersOtt <br /> 11'1Ilid vft fRatls <br /> 1k13?�IrA&fi€t"� qtr n far Tufa _oM.1ar Et t �, _I;,,;i-; j; "1 carl i,v Ihat in the performance of the work#or which this permit is issued,I shall <br /> +�Il,!a�ays,Qi i'iitR7.C1iJ. - <br /> I hereby certify that I have epared this application and th work will one in accordance with San Joaquin County <br /> ordinances, state laws, a es d regulatio of the San in Lac alth 'strict. a <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY -- <br /> ' <br /> Fee Is Due: 13ANNUALLY [JPER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received ByJnnuary 31 ❑ July 1 &Received By July 31 <br /> - - - - REMIT <br /> BASE EXPLANATION BILLING -REMITTANCE ,I $ �.�" AMOUNT DUE <br /> CHECKED <br /> DATE-r-- ` DATE REMITTED- AMOUNT <br /> FEE m <br /> LESS If <br /> PRORATION " <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No.— ermit o. sIssuance to Mailed Delivered i, Y <br /> APPLICANT—RETURN ALL COPIES TO:Y 'ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZELTON AVE P.O.Bax 2009 STOCKTON,CA 95201 <br /> s <br />