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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) <br /> SEPTAGE <br /> ENVIRONMENTAI. HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio hereby m de-to carry business in the jurisdict' nal area of the San Joaqu n L 1 Healt}`Dist t <br /> F Business Name (DBA) i�JJr� OitlSTiet/C7/e'�r(l Address ./L�. Tj�/Uc <br /> z Owner Address <br /> 2 Firm Partners, Addresses and Telephone Numbers - <br /> aBusiness Telephone No. 2d& -53_,SA" Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) � tle IiQ�A Date <br /> Please check Applicable Category (1-7) and Fill in the Required In to 2. <br /> 1- ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t �" <br /> For July 1, June 30, 19 DisposatSiteS — - } <br /> Description(Make/Yr., Color) <br /> Serial No. - CAL. License No. CAL. License Renewal No.- <br /> Capacity Gal.,Weights & Measures No. } ~.~ "• —j- - - <br /> Equipment Parking Address :f " J 4 <br /> ;.. <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 --�-- <br /> I <br /> R.S. or R.C.E. Name R.-P. or R.C.E. No. Cr <br /> Test,Lotion Test Date/,trime <br /> 4. N.s SANITATION PERMIT <br /> Job Address Location <br /> pwner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD R EPA(k PIT ❑ PACKAGE PLANT T <br /> 8 ERMANENT ❑ TEMP,O'RARYfW '," ' ❑ REPAIR ❑ bTFIEfi <br /> 0.. <br /> S. 11CHEMICAL TOILETS For July 1•, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(') f ' <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 t � <br /> Operator Name Where Certified <br /> r <br /> Plant Location <br /> Plant Capacity No. Units Served 4 ' <br /> �.. I . <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 j <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ! `� <br /> - <br /> NaKmawir�urlic�aesyent'ash,gtr+rs illINS omp& ajianfceF4ity�thati;etheofermaultaftheworkfarwht�M►3�ttis,permttfsissuect5haflnu?em,to an <br /> Cana.ctar's r as to Decome pct to wark>t yn's cany�etgatian favus rgfts #wof C dGMia.' i p Y Y A $art <br /> emptay p$rsons subfeet to workman pe"tl ywg � ft",*V' A Certify that it;the perfe mance of the wi k'for which'"this�prai'nit is tss&d.t snail <br /> r i y <br /> I hereby certify that I have p red this application and that t ork will be"done in accordance with-San Joaquin County <br /> ordinances, state laws, s and regulations of th a cal Health District. j <br /> APPLICANT'S SIS <br /> k / <br /> FOR DEPARTMENTiUSE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH d January 1 &Received_ By January 31 ❑ Jul 1 &Received By July 31 <br /> Y,_,:- <br /> w <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> - DATE DATE - REMITTED r T 1 AMOUNT <br /> FEE <br /> LESS <br /> PRORATION -- ' <br /> PLUS <br /> PENALTY - "6 <br /> OTHER tvap /01, I <br /> 1 - <br /> OTHER <br /> Received by -� Date Receipt No. Permit No. I uanc ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL E-,P.O.Box 2009 STOCKTON,CA 95201 <br />