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R ' <br /> Applications Will Be Processed When submitted Properly Completed. BeSureTo�g <br /> APPLICATION '" - <br /> '�'= (For Non-Translerable,Revocable, and Suspendable) -SEPTAGE <br /> ENVIRONMENTAL HEALTH-jPERM{T-� - <br /> LIQUIQ WASTE ` <br /> Application is her y made to car rry o business in t jurisdictional area oftFj�San aquin Local Health District <br /> y Business Name (DBA)t� 5 � - Address Y <br /> i Owner Address - ti <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No-. Emergency Telephone No-- - <br /> C .. <br /> Contractor Licence No. Date 1 ' <br /> Applicants Name (Print) Title <br /> Please check Applicable Category-(1-7)and Fill in the Required Information ,, - ;.. <br /> i. Xl- <br /> 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 - ` Disposal Sites <br /> Description(Make/Yr.,Color) <br /> CAL. License No. �� --'-� �• CAL-License Renewal No. <br /> Serial No. : a„� <br /> Capacity Gal.;°Weights & Measures No.� _�• <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> ,t <br /> For July 1, June 30, 19 <br /> No. Of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 1 � <br /> 3. ❑ PERCOLATION TEST r7 <br /> R.S.or R.C.E. No. <br /> R:S.or R.C.E. Name ,+- <br /> t I Test Date/Time <br /> Nest t cation I , <br /> '4SANITATION PERMIT 1' <br /> r iJ,ob Address/Lo ' n _, } <br /> Owner Address <br /> ❑ w LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE LANT <br /> ❑ SEPTIC TANK CESSPOOL r s ` � `� � <br /> 4KPERMANENT ❑ TEMPORARY ❑ NEW"" REPAIR OTHER <br /> I 5 ❑ Ck#EMICAL TOILETS For July 1, -June 30, 19Y I i ..� 61 `t t, <br /> Disposal Site— <br /> Co <br /> Type} nstruction ----•--�' <br /> No. of Units Equipment Storage/Cleaning Locations) �. <br /> c6.• ❑ PACI(AGE TREATMENT•PLANT For July 1, -June 309 <br /> W.,here,Certified.�.- <br /> Operatpr Name v ` <br /> plant•Location ' _ ,�� ��.r=�a a_i ;,,:�G�, ;,;. �3(�i `._�� '.". <br /> No_,Units Served t - <br /> Plant'Capacity <br /> �^ <br /> t For,July-l',F-Ju e.30,E197, El LAUNDRY <br /> r � ? <br /> SIZE: PEI <br /> Less Than 1,000 Sq. FX-, ❑ More Than-1,000 Sq.'Ft. <br /> i <br /> b,DRY CLEANING, Chemicals Used/Amount/Mo, <br /> - ' <br /> I herebyvice tify that I have prepared this application nn chat`the' orK fti be dpp e it accorda�ee with San=Joaquin County <br /> ^'o�dinances,`state laws, and rules a d r ati ns of the San Joaquin L cal_Hea'Ith District- �li'I <br /> APPLICANT'S SIGNATURE X �' <br /> .-FOR DEPARTMENT USE ONLY <br /> r+F„ Fee Is Dull ❑ ANNUALLY 1 PER UNIT ❑ PER SITE ❑ EACH A ❑ January 1 &Received By January 31 + ❑ July,-!. Received July 31 <br /> REMIT _ <br /> [. .x"` lam. BILLING REMITTANCE REMTTED AMOUXT.DU• RMOUNT <br /> { }BASE EXPLANATION ,DATE DATE -- <br /> 4 s, <br /> i FEE 'FP �LESSj' r <br /> PRORATION <br /> i <br /> PLUS: <br /> PENALTY y <br /> 4 OTHER <br /> 1! ` <br /> I OTHER <br /> F <br /> �.•E J <br /> � .. �► 16S3 r <br /> p+. � I seance Date Mailed De lvered <br /> Y <br /> Received by Date - Receipt No- ermit No. <br /> APPLICANT—RETVRN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E-HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201 <br />