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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Apptication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendabie) r SEPTAGE <br /> ENVIRONMENTAL HEALTH.PERMIT / <br /> LIQUID WASTE <br /> _ Application is hereby made to car on business in the jurisdictional area of the San JQ3pdi .Local HeaJlthDistrict.� <br /> prlj 1 Address <br /> r Business Name(DBA) Al <br /> ' <br /> aOwner 04 r�,� ,�f _ Address .. . _ <br /> L' Firm Partners,Addressesand T ephone Numbers <br /> r�.f1 <br /> Emergency Telephone No. -v <br /> aBusiness Telephone No. 51 <br /> Contractor Licence No. $ <br /> Title ` — Date <br /> L <br /> Applicants Name (Print) <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> y, ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 = _ =Disposal Sites - - <br /> Description(Make/Yr.,Color) y - CAL.License Renewat No. <br /> Serial No. —CAL. License No. <br /> Capacity TGaL,Weights&Measures No. s <br /> Equipment Parking Address _ fl <br /> 2. ❑ PUMPER YARD# <br /> t <br /> For July I.— June 30, 19 ; ) ' <br /> No.of Vehicles Stored I r <br /> No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST R.S.or R.C.E.No. <br /> R.S.or R.C.E.Name <br /> 4J <br /> Test Location : - Test Date/Timer" <br /> 4. ❑ SANITATION PERMITCI' 2 ` ��+ i�•d ` <br /> t S <br /> Job Address/Locations <br /> ,. <br /> Ow r Address <br /> EY <br /> �� �+ ❑ PACKAGE PLRN7 <br /> 1f,YSEPTIC TANK E3 CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR r <br /> ❑ C4;EMICAL TOILETS For July 1,-June 30, 19 j L <br /> pe Construction Disposal Site -- O <br /> vo.of Units Equipment Storage <br /> /Cleaning Locati0n(s) Va <br /> r <br /> g. ❑ PACKAGE TREATMENT PLANT for July 1,-June 30, 19 P <br /> � Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity i No. Units Served ``•, <br /> .I :1,,. <br /> 7, El LAUNDRY For July 1,-Juhe 30, 19 j.I <br /> ❑ More Than 1',000 Sq-Ft. I <br /> SIZE: ❑ Less Than 1,000 Sq.Ft., <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> + II t <br /> i <br /> I hereby ci rtiiy that I Nave prepared this a plication and that the work will be done in'accordance with San toi quip County <br /> ordinances, state laws,and rules and rag on�no he San Joaquin Local Health District. �1Y. <br /> APPLICANT'S SIGNATURE X <br /> 1 � e <br /> - ��'�'FQR-DEPAR°MENT-USE.ONLY-- <br /> Fee is Due: ❑ ANNUALLY} IJ❑ PEPz.IT ❑ PER SITE ❑_EACH ❑SJanuary7 S Received By January 31' ❑ dUly 1 &Receiv July 31 <br /> REMIT <br /> ✓i�+c. t� + ?'tL S \ CHECKED <br /> M S <br /> ii t BILLING RETANCE AMOUNT D <br /> 9A E 1 EXPLANATION BATE DATE;, REMITTED 4 �a AMOUN7 ' <br /> FEE <br /> LESS <br /> .PRORATION e v <br /> �4 C. <br /> ` s <br /> PLUS <br /> PENALTY <br /> OTHER d V "•� -I\ I' "?<t '�f'��f': +'�.i' 1^ <br /> _ O'C'HER <br /> t� t` Mallett Deliveretl <br /> t Date' Rec0x9 STOCKTON,CA 85201 <br /> eipt No- Permit No. <br /> Recewed by -I - The E_HAZELTON AVE,P.O.Box 2 <br /> AICANT�'RETURN ALL COMES TO: ENVIRONMENTAL HEALTH DERNIT/SERVICES <br />