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ApplicationsWill Be Processed When Submitted_Properly Completed. Be Sure To Sign The Application. <br /> T APPLICATION <br /> F 9 (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> �1 LIQUID WASTE , <br /> Application iapereby mad to carry on bust ess in the juris ictional area of the San Joaquin Local Health District <br /> mBusiness Name BA) <br /> Address - <br /> z Owner . Address4 <br /> Firm Partners, Addresses and Telephon umbers <br /> CL a Business Telephone No. �/&15- Emergency Telephone No. <br /> Contractor Licence No. 7- <br /> Applicants Name (Print) r- Title <br /> w�-w i-�s F-...-:. <br /> Please check Applicable Category(1-7) and�Flllthe Req�edormation <br /> 1. ❑-PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I For July 1, June 30, 19 ! Disposal Sites <br /> Description(Make7Yr.,_Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity li Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> t 2. ❑ PUMPER YARD :! <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored d <br /> . — <br /> 3. ❑ PERCOLATION TEST j <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> Test Lo tion Test Date/Time <br /> 4. W SANITATION PERMIT <br /> Job Ad�resslLoc�ation,, <br /> A ress <br /> Owner <br /> �'. ElPTIC TANCESSPOOL LEACHING FIELD 8 ; ❑ PACKAGE P NT b <br /> PERMANENT ❑ TEMPORARY ❑ NEW 0 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETSFor'li`July.1; --June 30, 19 <br /> Type Construction Disposal Site Z <br /> No. of Units s. Equipment Storage/Cleaning Location(s) .M. <br /> f <br /> fi. El PACKAGE TREATMENT PLANT For July'l June 30, 19 <br /> Operator Name <br /> Where Certified <br /> Plant Location ! , <br /> Plant Capacity "_ ` F No. Units Served <br /> R <br /> 7. ❑ LAUNDRY Fbr-Jelly 1-' :June 30`19..#-4_ _jAi - 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r <br /> ii !f <br /> I 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 regulatios of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X _LAC <br /> �®� <br /> t <br /> 3 <br /> Aj.l i y, <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH 13January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED - <br /> DATE DATE REMITTED AMOUNT <br /> !i <br /> FEE Y 'f <br /> 1 � <br /> LESS a <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1 :I <br /> i OTHER <br /> to i`Ct1 <br /> Received by Date Receipt No. Permit No. !iy^lt1O� Issuance Date Matted Delivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES „l X11601 E.HAZELTON AVE.,P.O.BoR 2009 -STOCKTON,CA 95201 <br /> r <br />