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s <br /> Applications Will Be Processed When Submitted Properly Completed.BSure <br /> APPUCATIO_N <br /> y s (For Non-Transferable,'Revoc able` , 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 San.doaquin Local Health District <br /> `Address �U <br /> yBusiness Name (DBA) <br /> 4.Gc_ <br /> 'Address <br /> a Owner <br /> J Firm Partners, Addresses and Telephone umbers <br /> IL Business Telephone No. — � Y _ Emergency Telephone No ; <br /> Contractor Licence No. ,, _eA Date <br /> �Applicants Name (Print)_ cE.aJy b Title, <br /> t <br /> Please check Applicable Category (1-7).and Fili in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) – <br /> For July 1, June 30, 19`I -,-Disposal Sites - - <br /> Description(Make/Yr., Color) CAL. License Renewal No.-^r <br /> Serial No. CAL. License No. <br /> fCapacity !` Gat.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ~ <br /> For July 1, - June 30, 19 " <br /> 'No. of Vehicles Stored ? r <br /> No. of Chemical Toilets Stored <br /> 3. 11 PERCOLATION TEST 'S ' <br /> ' R-S. or R.C.E.No A., ' <br /> R.S. or R.C.E. Name <br /> Test Location` Test Date_ <br /> /Time <br /> 4. 13 SANITATION PERMI+T l ry �� +_ �� 74J <br /> Job Address/Location k'19 <br /> ` .S Address <br /> Owner� �_ ❑RPACKAGE PLANT <br /> Q S <br /> } SEPTIC TANK CESSPOOL EACHING FIE �❑ SEEPAG -'g' �❑ OTHER <br /> ❑ PERMANENT # <br /> ❑ TEMPORARY ❑ NEW .� REPAJ -R` <br /> . . <br /> All <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 /> ` a <br /> 6. ❑ PA-&K"-TR IEATMENT PLANT For July 1,-June 30, 19 1 } <br /> I <br /> Where Certified, <br /> Operator Name <br /> Plant Location <br /> 'F No. Units Served <br /> Plant Capacity '" " <br /> { 7, ❑ LAUNDRY-t 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 /> AfV <br /> cwt`s <br /> hereby certify that.l have p epared this application aiid that the work will be done in accordance with San Joaquin County <br /> t ordinances, state laws, and rules and regIations of the San Joaquin Local Health_ tric <br /> _Dist. <br /> APPLICANT'S SIGNATURE X _ <br /> ©L <br /> J. FOR DEPARTMENT USE ONLY <br /> f� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT _❑ PER SITE EACH ❑ January 1 &Received By`January 31 ❑ July 1 &Received By July 31 <br /> - REMIT <br /> t�'• BILLING REMITTANCE $ <br /> � AMOUNT DUE CHECKED <br /> BASE EXPLANATION .DATE DATE REMITTED AMOUNT - <br /> FEE <br /> K <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER * r <br /> OTHER <br /> ` "'` 'ReceipCNo-." Permd No- lssua ce'Date: M fled" <br /> * � Delivered' <br /> c Received by <br /> ' APPLICANT—RETURN ALLCOPIES YE. Boa 2009 STOCKTON,CA 95201- <br /> TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON A , . <br />