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r.Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> f APPLICATION ` <br /> � •` 3 `'� w $ (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> " ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is eb made t nun business in the jurisdictional area of the San JoA}1i�n Loc I.Health District <br /> F Business Name BA D U Address <br /> ti <br /> z Owner �i7 ` � ^' �- Address�L`� <br /> _ F .- <br /> J Firm Partners, Addresses and Telephone Numbers t <br /> CL Business Telephone No. - Emergency Telephone No.� <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title_ Y Date <br /> Please check Applicable Category(1-7)and Fill In the Required_Information ., - M; ,. �L <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> # For-July 1, June 30, 19 Disposal Sites -. . _.m- <br /> Description(Make/Yr., Color) <br /> i# Serial Na. I CAL. License No., CAL. License Renewal No. <br /> f Capacity' Gal:, Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 1 <br /> For July 1, June 3Q;1 9' <br /> No. of Vehicles Stored `-, a- ^" <br /> ( No. of Chemical Toilets Stored . <br /> I 3. ❑ PERCOLATION TEST K <br /> R.S.or R.C.E. Name ' R.S-or-R.G:E-No- " <br /> Test L cation �. Test Date/Time f <br /> G 4. SANITATION PERMIT <br /> 17 <br /> Job Address/ ati <br /> Address <br /> EPTIC TANK -❑ CESSPOOL = LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT= I <br /> PERMANENT ❑ TEMPORA_RY - NEWS -REPAIR ❑-OTHER <br /> ❑ S <br /> // <br /> 5. CHEMICAL TOILETS For July 1, -June 30, 19 _ -- r <br /> Type Construction 1 -Disposal Site <br /> p <br /> YP i _ <br /> Z7 - No. of Units, j.Equipment Storage/Cleaning Location(s) <br /> S 6. ❑ PACKAGE_ TREATMENT PLANT;;,For July 1, -June 30, 19 ' <br /> Operator Name Where Certified <br /> I' Plant Location a uj �IA <br /> ZR—Plant Capacity No. Units Served <br /> 17. ❑ 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 regulatons f t San Joaquin Local'F9ealth,Disfrict. i <br /> APPLICANT'S SIGNATURE X <br /> , S <br /> FOR DEPARTMENT USE ONLY- <br /> Fee <br /> NLYFee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 $Received By January 31 ❑ July 1 &'Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE ,$ _ <br /> BASE EXPLANATION AMOUNT OUE CHECKED <br /> - - - - -.OATE DATE - REMITTED AMOUNT " " <br /> FEE <br /> LESS • ` <br /> PRORATION <br /> PLUS J4- - <br /> PENALTY - <br /> OTHER ;. <br /> _OTHERr <br /> Received by 'Date Receipt No. Permit No. Issua-_D Mailed Delivered' <br /> 1 APPLICANT—RETURN ALLL COPIES TO: - ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON .,P.O.Box 2009 STOCKTON,CA 95201 <br />