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Applications Will Be Processed When Submitted ProperlyFFcompleted. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferabie,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> `` LIQUID WASTE <br /> Application is hereby made to carry on Uusmess in the jurisdictional area of theSanJoaquin Local Health District <br /> H Business Name (DBA) I►1 I.fil j� JC Address '�C�1.x.1 C�ItA TC' '— - <br /> iOwner-��t=.�1 a�1��� Address S�'Y_1_G ------ <br /> J Firm Partners, Addresses arldGTelephone Numbers — -- - -- <br /> iBusiness Telephone No. ��d -� S�' ( — Emergency Telephone No. <br /> Contractor Licence No.3_�5 1 <br /> Applicants Name (Print) 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 --No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name _ -_ R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PET 1 ++ `> _ <br /> Job Add /L tion �( I <br /> 1 V 1 ! 9� — <br /> Owner �' l t� L C�1� Address{ c� est1� F ----- <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 13TEMPORARY NEW REPAIR 1:1 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 have prepared this appiicatio and that the work will be done in accordance with San Joaquin County <br /> ordinances,state law ,a rut s andegul ion of i'iz oaq 'n Local Health District. <br /> APPLICANT'S SIGNATURE -- <br /> o ' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 B Received By July 31 <br /> REMI <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNTOUE CHE <br /> DATE DATE REMITTED A M"If <br /> NT _ <br /> FEE <br /> LESS -- -- � w <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 1 <br /> OTHER -- <br /> ill 1 4 _ 14 I <br /> r,� : i 1 -`� ! ?� int <br /> Received by to Receipt No. Permit No. ante a ai ed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bea 2009 STOCKTON.CA 95201 - <br />