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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <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 /> r _ /. r,- r—f—,til <br /> y Business Name (DBA) �r'l—r}-t��� i,�1"r�., tC;- :'��/.."r �- .`L`-'• Address 1�.CC- 1.= � C� C <br /> z Owner Address �� f''Z' r C la <br /> J Firm Partners, Addresses and Telephone Numbers L <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 19 —7-5 <br /> Applicants Name (Print) 3' tit I'I `` 'tel`- Title f t 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 <br /> No. of Chemical Toilets Stored <br /> 3. 9 PERCOLATION TEST _ <br /> R.S. or R.C.E. Name k(!.� r1F�j.� .>c�til xLh/f r r c��f e R.S. or R.C.E. No. Z3Z-G-1 <br /> Test Location ' ' ,:',--.t t�7C7� +*) � Test Date/Tim r —� <br /> 4. [3 SANITATION PERMIT <br /> TESTS f r!' '�, i� <br /> Job Address/Location <br /> Owner 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 /> 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 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 regulations 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 ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE J? /,�-QU <br /> LESS Cl V V <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ,'``I/`` '` <br /> �W. V Q <br /> 41� S 100 754� 6 <br /> Received by Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />