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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign <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 business in the jurisdictional area of the San Joaquin Local Health District <br /> Business N me (DB Addre - <br /> Lice <br /> z Owner � � rt Address <br /> 1 J Firm Partners, Addresses a TI ho Nu b rs <br /> j Emergency Telephone No.: <br /> a Business-Telephone No.— <br /> Contractor Licence No. 11.)AA7-1 , Date <br /> Title <br /> Applicants Name (Print) , <br /> Please check Applicable Category(1-7)and Pill in the Required Information <br /> IN <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 3l - Disposal Sites- <br /> , Description(Make/Yr., Color) KCAL. license Renewal No. <br /> ' Serial No. CAL. License No. i <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 f t <br /> -j I i <br /> i <br /> No, of Chemical-Terlets-Storeci <br /> 3. ❑ PERC LATION TEST <br /> R.S.or R.C.E�IVam'et} < 1, 1` R.S. or R.C.E.No. I = <br /> Test Date/Time <br /> Test..Loationt <br /> q, lid'SANITATION PERMITt <br /> yy i <br /> Job Address/ ocatio <br /> All, <br /> ���� <br /> Address <br /> El SEPTIC TANK C3 CESSPOOL W LES ACHING FIELD IiOwner -I'VE AG T ❑ PACKAG PLANT k <br /> 9I"�ERMANENT ❑ TEMPORARY .- 0 NEW 1 t REPAIR ; ❑ OTHER <br /> i <br /> 5. <br /> 11 CHEMICAL TOILETS For July 1, June 30, 19 .! <br /> Didposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) f+ <br /> a 7 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-4ne 30, 19 <br /> - �__Where•Gertifled- � ----� <br /> Operator Name ' <br /> Plant Location <br /> Zta <br /> No. Units Served <br /> Plant Capacity u <br /> +.-t o <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19;__ _-1 � <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 11 Mo�e.,Than1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals . <br /> Used/Amount/Mo :. ; <br /> i -2 <br /> � �i <br /> I hereby certify that i have prepared this ap rlication and that the work will be done in accordance with San Joaq;In County *` <br /> ordinances, state laws, a s and r lations-Al..ttte.Saq_loaq�in_Lo�aliealt District. (� <br /> APPLICANT'S SIGNATURE X <br /> 42, <br /> r <br /> FOR-DEPARTMENT USE,ONL <br /> fee IS Due: ❑ ANNUALL^Y -\ O:.PER.CINIT• ;0-PEFt SITE*--c'^..0`EACH"` QyJanuaryl &Rec@iyed'$y Janu2frr�31 ❑ July 1 8 Received By July 31 <br /> ,., REMIT <br /> �, BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE '� EXPLANATION !' DATE-— DATE - REMITTED AMOUNT <br /> FEE <br /> sal ` <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY , <br /> OTHER <br /> OTHER <br /> T <br /> Received by <br /> Date Receipt No. Permit No. Is uance ate Mailed Delivered <br /> APPLICA —RETUFIN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITI5ERYICES <br /> 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95241 <br />