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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> f)r C (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> l( ) ENVIRONMENTAL HEALTH PERMIT <br /> r <br /> LIQUID WASTE <br /> Application((is hereby made to,car� Qn busir ss in thejuris¢ictional area of the San Joaquin Local Health District <br /> F <br /> y Business Name (DBA) - _1�:z �:.A W1 Q A L 'J� (/A L L --4V,,/v/• t-I= �­� L u <br /> w <br /> a Owner t '� ( L r� Address it <br /> J Firm Partners, Addresses and . <br /> Tele hone Numbers <br /> o. Business Telephone No. ­26 � �-'�' y Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print.) a' 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. of Chemical Toilets Stored <br /> 3. PERCOLATION TEST t <br /> R oP R.C.E. Name r., (} h L ?_ ra. • 4R5=w R.C.E. No. <br /> Test ocation Test Date/Time <br /> Job Address/Location �'J/( P z? ; '�.,-� <br /> Owner `L;Fi'V S C u T c t C3 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 <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 agrorregulations of the San}oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 /> Rgce ed by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> / PLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />