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Applications ill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. s <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is,hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health Dls <br /> y <br /> -l3usiness Name (.DBA) 1 v � ' 1 fir`' �' Address '' n-ate <br /> �{ <br /> i z Owner .,.. 7 I' '< Address :a `•°x`�"` <br /> Firm Partners, Addresses and Telephone Num66rs <br /> IL x f . / x Emergency Telephone No. <br /> IL Business Telephone No. 1 <br /> A Contractor Licence No. " {` <br /> a �, 4.- r: Title _ 1 Date T�' <br /> LAppllcalots.Name (Print) <br /> Please'heck Applicable Category (1'-7) and Fill in the Requird Information <br /># 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 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 /> t <br /> Equipment Parking Address <br /> 2. ❑ PUIII YARD ° <br /> For July 1 y' June 30; 1,9� <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored - <br /> 3. ❑ PERCOLATION TEST s <br /> R.S. or R.C.E. Name. I R.S.or R.C.E.flo. <br /> -'1-est Date/Tirrie <br /> r Test Location W <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Locatio -: <br /> » ) �' <br /> Yu ".:Address.' ?OPAC <br /> O <br /> wer <br /> 9I*J,SEPTIC TANK ❑ CE SPOOL ❑' yLEACHING FIELD 0 SEEPAGE PIT GE PLANT <br /> EIPERMANENT ❑ TEMPORARY ' NEW ❑ REPAIR ❑ OTHER = <br /> # ` . <br /> 5. 11 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 /> v+� <br /> Plant Location <br /> Plant Capacity <br /> No. Units Served - <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 w h ` '•r <br /> SIZE: ❑ Less Than 1,000 Sq, Ft., ❑ More Than.1,000 . <br /> Sq_Ft. '- <br /> .. <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 actortancfwith San Joaquin County <br /> ordinances, state laws, and rules,41 regulations of t�San Joaquin Local Health District. <br /> a ,.. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ anuar Received By January 31 ❑ July 1 &Received By July 31 - <br /> REMIT <br /> BASE EXPLANATION BILLING REMITT $ AMOUNT DUE CHECKED <br /> DATE DA REMITTED AMOUNT <br /> FEE <br /> LESS f <br /> ,-PRORATION <br /> PLUS <br /> PENALTY +. - <br /> OTHER A <br /> fl <br /> OTHER <br /> 1�/toy cc -S ca �tl <br /> Received by Date Receipt No, Permit No. issuance 131ale Mailed Delivered + <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEpMIT1SERVICES 1601 E,HAZELTON.AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />