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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transierable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the Sap4aquin'Local Health District <br /> Business Name (DBA) FcrL E..� I�'tr Address <br /> aOwner Q_..�, ri�� 'C,;� Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. 5 f Emergency Telephone No. <br /> a <br /> Contractor Licence No. - <br /> Applicants Name (Print) r�/G ` TitleDate <br /> Please check Applicable Category (1-7) and Fill in the Required Information S- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) +' <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> i Serial No. CAL. License No. CAL. License Renewal No. <br /> 4 Capacity Gal., Weights & Measures No. I _ <br />€ Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored ' <br /> No. of Chemical Toilets Stored <br /> ro re <br /> 3. ❑ PERCOLATION TEST f <br /> k R.S. or R.C.E. Name - _ _ R.S. or R.C.E. No. <br /> Test Location, - �""""'�"""�-=' Test Date/Time <br /> 4. ❑ SANITATION PERMIT � y <br /> ' Job Address/Location 2y ,r [..�k L11,� P D ^ <br /> ,, Owner - ,,��,,��� Address ' � �+�G' - —1 <br /> ❑ SEPTIC TANK,. ©CESSPOOL I�LtACHING FIELD> ❑tS PAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT; " ❑ TEMPORARY .❑ NEW g AIR ❑ OTHER 3y. <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 1,9k <br /> Type ConstructionDisposal Site �. <br /> No. of Units ^ _ Equipment Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1,=June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity 1 LL No. Units Served t <br /> aw . <br /> " 7. El LAUNDRY For-zluly-1June-30r-1'9 .- <br /> SIZE: ❑ Less Than-1,006 S4-Ft., ❑ More Than.1,000 Sq. Ft. <br /> ❑ DRY CLEANING, CI emicalstUsed/Amount/,Mo.-!- _ <br /> a <br /> f t ,t -+ ; <br /> I hereby certify that I have�preparedetbis_application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws;rand rules and r gul 'ons of the San Joaquin Local Health District. <br /> I 6 <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY ^; <br /> Fee Is Due: ETANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 - ❑ July 1.&Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> as <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS e <br /> PENALTY lG "Is -4F <br /> f OTHER ' <br /> OTHER; <br /> Lr r: <br /> i Received by Date Receipt No. Permit No Iss ance ipate Mailed Delivered <br /> '1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES - . <br />