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Applications Will Be Processed When Submitted Properly Completed. BeSureTosign lnefappucauun. <br /> APPLICATION <br /> _K r (For Non-Transferable,itrleuoaBTe,and Suspendable) SEPTAGE <br /> y ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i reby made carry n business i the.jurisdictional area of th�S�an Jo qui�ocal Health District <br /> ,�Business Name (DBA) Address�T — <br /> aOwner Address <br /> u Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. 4 a" Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) ��1 O Title pate <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 <br /> Gal.',Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD l's 9� <br /> For July 1, June 30, 19t <br /> No. of Vehicles Stored ` <br /> No. of Chemical Toilets Stored ` <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.C.E.No. <br /> Test ocalion '^ I Test Date/Time <br /> 4. SANITATION PE I <br /> J&_Addr Location o <br /> Address <br /> Owne11 <br /> r _ •` ~❑ PACKAGE PLANT <br /> ❑ SEPTI TANK -❑"GESSPOOL k LEACHING FIELD SEEPAGE PIT <br /> ❑ PERMANENT ❑ TEMPORARY', '❑ NEW ' REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19' <br /> .» #v <br /> ' . f�'+ Dis osal Site <br /> Type Construction "`�- p - t�fx <br /> � '' � t"� Equi rren1,Stora dCieaning Location(s) ' <br /> No. of Units P 9 t <br /> 6. 11-PACKAGE TREATMENT-PLANT For July 1, -Jurte,30,19; - <br /> ' At. Where Certified <br /> Operator Name-., <br /> Plant _ �� �t� No. Units`Served <br /> Location t, <br /> Plant Capacity , - I r <br /> 7: ❑ LAUNDRY, For Juiy 1, -June 30, 19 -' <br /> 0 1 <br /> ;51Z�E.', -0 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 5q. Ft. y j <br /> s� I�At , <br /> 0 DRY rLNING,.Chemicals Used/Amount/Mo. t <br /> lA hereby certiffi that'�j-<ave prepared this application and that the`Workrwill be done in accordance with San Joaquin County <br /> ---,l <br /> `ordinances, s)'ate laws,-and rules and r gulatio the S Oa Lim Local Health District. ) + <br /> APPLICANT'S SIGNATURE X <br /> A <br /> FOR DEPARTMENT USE ONLY # <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE. 11EACHi ❑ January 1 &Received By January 31'. © July t &Received By July 31 <br /> �- ---- - ! REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT.DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> PLESS <br /> RORATION w � <br /> PLUS <br /> PENALTY <br /> OTHER L <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date m,M3iled-�,, Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT�SERVICES tt °'may 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />