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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Translerable, Revocable,and Suspendabte) / SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT [ i <br /> LIQUID WASTE <br /> Application is hermade to carry on business in the jurisdictional area oft San Joaquin Local Health District <br /> rn Business Name (DBA) eb ! ��- Address S �o � �� <br /> aOwner . Address - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. J�� �� <Emergency Telephone No. 3 <br /> Contractor Licence No. <br /> Applicants Name (Print) � ;SIUS Title �,T1!! t i!�'T�P Date <br /> 1 <br /> Please check Applicable Category (1-7)and Fill-in the Required Information • ; <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) -� <br /> Foi•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. n <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. ❑ PERCOLATION TEST "►. ; <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location { Test Date/Time <br /> 4. 9-SANITATION PERMIT ' <br /> Job Address/Location GA !;;' O K A e7 S-rr- . <br /> Owner Address <br /> ❑ SEPTIC TANK 0 CESSPOOL ❑ LEACHING FIELD zz:❑•SEEPAGE PIT,r. ❑ PACKAGE PLANT 0 <br /> ❑ PERMANENT © TEMPORARY ❑ NEW ❑ REPAIR - OTHER J&A)_)b0Q TIG-rA74 tL i <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction { ,. .Disposal Site <br /> No. of Units a Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name ` -'' ,, ` ` ` F Where Certified <br /> Plant Location <br /> Plant Capacity " No. Units Served ; ) <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 -•� f` I" <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 appli GatioDand that the work will be done in accordance with San Joaquin County <br /> ordinances,,state law les and re lations a San quip cal Health District. <br /> AD <br /> APPLICANT'S SIGNATURE T.f <br /> , S•r J rr <br /> FOR DEPARTMENT USE ONLY + <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH', ❑ January i &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 /> FEE 1 <br /> LESS ! <br /> PRORATIONTT <br /> PLUS <br /> PENALTY - - <br /> w_* <br /> OTHER- <br /> OTHER <br /> i Received by Date - Receipt No. Permit No. ,_ �E Issuance Date Mailed D <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 . <br />