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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.f <br /> �. APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h^ereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H _4siness Name (DBA)— 454eZ.& -R- Addresses a/3* <br /> Owner C.sE� Address <br /> Firm Partners,Addresses and Telephone Numbers <br /> iBusiness Telephone No. S- �- Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants NamTitle 0:rw 4.zg�7e Date 02n 7 I <br /> Please check Applicable Category(1-7)and Fill in the Required information �J <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 '`s <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> Test Location _-_ Test Date/Time - <br /> 4. ❑ SANITATION PERMIT LQ 1 -f> <br /> Job Address/Location4 /G R —`72AC <br /> Owner 5% 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 /> 1e Construction ' ";' s. Disposal Site <br /> m <br /> of Units Equiperit Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,,19_._ <br /> Operator Name " '- " , -.__.—_Where Certified r <br /> Plant Location <br /> ,i. <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 0 O Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 1 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 and r uiati s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X + <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due.- ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE - ❑ EACH CJ January 1&Received By January 31 ❑July 1&Received By July 31 <br /> _._...._._..........__._.__.__._.._........_..........._......_ —_.. .- <br /> S REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION AMOUNTOUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE y <br /> LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY <br /> OTHER - <br /> I <br /> OTHER <br /> Received by Date Receipt No. Permit No. Puanc6f Datel Mail Delivered <br /> • APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bot 2009 STOCKTON.CA 95201 <br />