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APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> +i LIQUID WASTE <br /> Application is her by made to carry on business Int a Jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBX c � Address-_ n - <br /> ` Owner m- Address— -- -- <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. _ II. Emergency Telephone No. - - - <br /> Contractor Licence No. -3 .1 <br /> -- - ---� <br /> Applicants Name (Print) — Title --- 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) -- <br /> Serial No. CAL. License No. -- CAL.License Renewal No. <br /> Capacity _ '�` Gal., Weights 8 Measures No. - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles StoredNo. 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 — Ib Test Date/Time <br /> 4. 11 SANITATION PERMIT <br /> Job Address/Location 4 <br /> - <br /> Owner ,,{�'s�l - Addres,-s•�._ <br /> SEPTIC TANK ❑ CESSPOOL LEAC NG FIELD L��SEEPIT ❑ PACtKAtE LANT <br /> PERMANENT ❑ TEMPO IRARY NEW 11 REPAIR ❑ OTHER �� a <br /> 5. 1:1 CHEMICALTOILETS For July 1, -June 30, 19 i <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 �f - <br /> Plant Capacity I� -. No. Units Served _- <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 — <br /> SIZEI 13 Less Than 1,000 Sqh Ft., More Than 1,000 Sq. Ft <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. -. --- - - <br /> I hereby certify thatl have prepared this application and that.the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r le nd gulatto i"f the San Joaquin ocal Health District. <br /> APPLICANT'S SIGNATURE X 'II T r - -- <br /> 1 _ FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PFR SITE ❑ EACH ❑ January 1 &'Received By January 31 ❑ July t &Received By J•,.ly 31 <br /> -- —� -i - REMIT <br /> T� BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE E%PLANATION DATE 1 DATE REMITTED AMOUNT <br /> FEE --- <br /> LESS II� O <br /> PRORATION <br /> PLUS 111 VVV <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 - r <br /> +Bei i <br /> cei <br /> Reved by Dite Receipt No. Permit No. 1T- ss ce ID Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE_,P.O.Bolt 2009 STOCKTON,CA 95201 - <br />