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=- y,. ..._. <br /> • �, Appllcafiona Will Be Processed When Submitted Properly Gompletera• a ouiv 1.�'. i <br /> ;; APPLICATION <br /> (For Non Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> UQUID WASTE <br /> I is h reby�]ade to carry on busses in the jurisdictional area of theyn Jo In Local Health District <br /> Applicati <br /> Address I'6. go <br /> i I-Business Name(DBA) r -.-=•--• Address <br /> Owner <br /> j.Firm Partners,Addresse4andTdl�e-pho�n,e tubers Emergency Telephone No. <br /> aBusiness Telephone NO•-j Contractor Licence No. TitleDate <br /> Applicants Name (Print <br /> Please check Applicable Category,(1-7)and Fill in the Required Information Oi-) <br /> O <br /> 1• ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) f <br /> For Jdly 1, June 30, 19 p Disposal Sites <br /> V) <br /> Description(Make/Yr.,Color) CAL.License Renewal No. '..� <br /> j' <br /> Serial No. CAL.License NO. <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, <br /> June 30,19 <br /> � <br /> No,of Vehicles Stored _ <br /> r No.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST U R.S.or R.C.E.No. <br /> R.S.or R.C.E.Name ;F Test Date/Time <br /> j Test LLocation <br /> 4. ,ra SANITATION PERMIT // y <br /> C <br /> I. Job Address/Loc tion Address 9-0 <br /> Owner II�I0 PACKAGE PLANT V <br /> SEPTIC TANK 0 LEACHING FIELD X SEEPAGE PIT OTHER <br /> ❑ TEMP.ORARY 25 NEW' O REPAIR <br /> PERMANENT <br /> 5. 11CHEMICAL TOILETS For July 1,-June 30,19 <br /> Disposal Site <br /> I Type Construction }.. <br /> No. of Units !t. Equipment Storage/Cleaning Location(s) <br /> F <br /> is 6. ❑ PACKAGE TREATMENT,iPLANT For July 1,-June 30,19 Where Certified <br /> Operator Name <br /> Plant Location 3• No.Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,=--June 30, 19 <br /> ! SIZE: C3Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,-Chemicals Used/Amount/MO. ` <br /> If <br /> 1� <br /> ' 1 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 r es and regulations o the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> inn < rI� •• � 2 5/-D <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> I REMIT <br /> Fee I5 Due: ❑ ANNUALLY ❑ PER-UNIT ❑ PER SITE ❑ EACH Q January t&Received By January 31 July 1 8 Received By July 1 <br /> to BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE ' EXPLANATION DATE DATE REMITTED AMOUNT <br /> ysa4; <br /> FEE !," <br /> LESS =¢t <br /> PRORATION <br /> [< PLUS <br /> PENALTYit �y <br /> i. .I <br /> OTHER <br /> OTHER I <br /> _ 07 0 5 <br /> r Received by ":•Date <br /> Receipt permit No. Issuance Date Mailed Delivered <br /> ENVIRONMENTAL HEALTH PEAMiTlSERVIGES 1641 E.HAZELTON AVE,,P.O.Bot 2009 STOCKTON,CA 85201 <br /> APPLICANT—RETURN ALL COPIES TO: <br /> _ :tea.-..��.•_. <br />