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Applications Will Be Processed When Submitted Properly Completed. BeSureToslgn Inemmill u.. • <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 He��Dis r tL <br /> Address <br /> y Business Name (DBA) <br /> z Owner =�LLQ— Address <br /> a x <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> CL Business Telephone No. <br /> a i d <br /> Contractor Licence No. Date <br /> Title <br /> c Applicants Name (Print) I-vC W� <br /> i Please check Applicable Category (1-7) and Fill in the Required Information' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) y <br />(" For July 1, June 30, 19 Disposal Sites <br />►, Description(Make/Yr., Color) <br /> Serial No. <br /> CAL. License No. CAL. License Renewal No. <br /> Capacity -- V GaI-"Weights &Measures--No. - <br /> Equipment Parking Address i, r <br /> 2. ❑ PUMPERYARD <br /> For July 1, June 30, 19-�� <br /> r <br /> No. of Vehicles Stored -11 <br /> 0 1 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST or R.G.E. No. <br /> ( R.S. or R.C.E. Name _ -*-•-+��' <br /> t _ Test Date/Time <br /> Test Location *- '�- +i: - r 1 <br /> I 4. ❑ SANITATION PERMIT t " `� 41,9-41's r10 <br /> Job Address/Location <br /> Own /7i �.9."#.• Address t <br /> { ❑ CESSPOOL A EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> f I�SEPTIC TANK ❑ REPAIR 11 OTHER <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW'' <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19. ,- "" •� -. <br /> Type Construction i Disposal Site <br /> No. of Units Equipment Disposal <br /> Location(s) <br /> i 1 <br /> -41 <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19� Where Certified <br /> Operator Name <br /> 1 Plant Location 4 <br /> _ No..Units Served <br /> Plant Capacity f '' <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 . <br /> SIZE: ❑ Less Than 1,000 Sq. Ft', El More Thari1,000 Sg. Ft. <br /> 6 ❑ DRY CLEANING,Chemicals Used/Amount/MO. _ <br /> L <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and �reg ' of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> j FOR DEPARTMENT USE ONLY <br /> �- <br /> ❑ ❑ ER SITE ❑ EA ❑ January 1 8 Received By January 31 E3 July 1 &Received MIT, 31 <br /> Fee Is Due: El ANNUALLY PER UNIT P <br /> NATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION DATE DATE REMITTED AMOUNy <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS —PL <br /> F PENALTY - <br /> { OTHER <br /> OTHER <br /> Date - Receipt No- Permit No Issuance Date Mailed Delivered 95 <br /> -�/ <br /> Received by - - 1601 E.HAZELTON AYE.,P.o.Box 2009 STOCKTON,CA e5301 <br /> I APPLICANT-+RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES m <br />