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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 hereby made to carry on qusiness in the jurisdictional area of the San Joaquin Local Health Dist ri t <br /> rn Business Name (DBA)—Tr{�JCJ4&s� w� iI"/4 -SO Address zszr'- n /21<d,(�o- � <br /> i Owner Y111P f 2S- �R �b 01'r0'!_Y0 Address 1271!91 -2044 rSC <br /> a r—TrT� <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. �J�/�-�3 4� Emergency Telephone No. <br /> Contractor Licence No. _ <br /> L Applicants Name (Print) r �U 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 & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. o1;Chemical Toilets Stored <br /> 3. PERCOLATION TEST <br /> R.S. or R.C.E. Name go /`J R.S. or R.C.E. No. <br /> Test Location _ft:Z� E L e5 1A r SG 9TH ate/Time 12-6-1? 7 <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner 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 <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 Od <br /> Plant Capacity No. Units Served 04 <br /> 0 F <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 j _ <br /> SIZE: 11 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. .J <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. Air <br /> �l`/�YJi <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun y <br /> ordinances, state laws and r les and regulations of the n Joaqui Local Health District. <br /> APPLICANT'S SIGNATURE X nn <br /> 14 <br /> t 0 -$ 7 1',�u C-_ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ 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 <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -� /0 <br /> Receive by Date Receipt No. Permit No. Issuance Date Mailed Delivered • <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />