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r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> �. (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is he/r by made to carry on business in the jurisdictional area of the S Joaquin Local Health District <br /> F Business Name (DBA) t^'�1 /. v J! Address�7 aC4 Ing � ��A � <br /> z OwnerAddress <br /> a ,a <br /> J Firm Partners, Addresses and Telephone mbers _ <br /> aBusiness Telephone No. � Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name Name (Print) 04 . TitleDate <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& Measures No. - Y. <br /> Equipment Parkirt>g Address <br /> 2. ❑ PUMPER YARD <br /> Y <br /> For July 1,. June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST. ' 3 <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 /> Job Address/Location <br /> a,v 2'.4 .� n� I> o <br /> Owner7412%,,l GaC Address <br /> ❑ SEPTIC TANK-.' CESSPOOL ❑ LEACHING FIELD .❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 1 _ <br /> Type Construction Disposal Site + {i <br /> No. of Units Equipment Storage/Cleaning Location(s) !� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name y Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY. For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq: Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ' <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, and rules and reg do the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> rA �� <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE — ❑ EACH T❑-January 1.&-Received.-By January 31 ❑ July'1 &Received By July 31 <br /> BILLING REMITTANCE g REMIT <br /> BASE EXPLANATION DATE DATE REMITTEfl AMOUNT DUECHECKED <br /> �— AMOUNT <br /> — <br /> '"' FEE <br /> LESS <br /> PRORATION <br /> PLUS 80se <br /> PENALTY <br /> OTHER <br /> OTHER <br /> s3 3 7 0/ ,Fy �jl8fdb <br /> Received by Date Receipt No rmit No. Issuance Date Mailed veered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,-CA.95211"" =!f� <br />