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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheAppneanon. <br /> APPLICATION I <br /> (For Non-Transferable, Revocable,and Suspendable) / SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District,, , <br /> Business Na f e (DB ) i Address sp �4 C1 <br /> z Owner L "`/a Address <br /> a <br /> J Firm Partners, Addresses and Tele hone Numbers _ 1 <br /> aBusiness..Telephone No. <br /> Contractor <br /> Emergency Telephone No. <br /> Contractor Licence No.Yy!J2-I fps r <br /> LS NaMe (Print) r < Title �h/I'1 eY Date <br /> .. • � <br /> Please check Applicable Category.(1-7).and Fill In the equired Information.,, .* <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) v ► I <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 Gal.,Weights & Measures No. <br /> Equipment Parking Address f I <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored 1 <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 /> �. <br /> 4. ❑ SANITATION PERMIT k7 S S <br /> Job Address/Locatign d <br /> Owner Address <br /> O <br /> OI�il r llt ❑ PACKAGE PLANT. 4 <br /> r SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ^ la SEEPAGE PIT 13 OTHER # <br /> PERMANENT C1 TEMPORARY M NEW F ❑ REPAIR i <br /> ❑ CHEMICAL TOILETS For July 1,-,lune 30, 19 <br /> -Type Construction k Disposal Site <br /> `No. of Units f Equipment Storage/Cleaning Location(s) 21, <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name { V1 <br /> Plant Location a <br /> o. Uri its Sery <br /> Ned ` <br /> Plant Capacity I E <br /> 7. ❑ LAUNDRY For July..1, -pJ:une 30, 19 y' �• <br /> SIZE: ❑ Less Than 1,000 Sq Ft., 11 More Than 1000 Sq. Ft. <br /> �^ ti 1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Ni <br /> I hereby certify that 'have prepared this-application and that the work will be done in accordance with San Joaquin County <br /> f the San doa uin'Local Health District. r <br /> ordinances, stake <br /> laws and rules and re ulations o , <br /> APPLICANT'S SIGNATURE X _ 6 <br /> FOR DEPARTMENT USE ONLY ,. <br /> Fee IS Due: ❑ ANNUALLY ❑ PERUNIT ❑ PER SITE ❑ EACH -❑ January 1 &Received ByJanuary 31' ❑ July 1 &`Received By July_31 <br /> -. -TREMIT <br /> I I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> r BASE' EXPLANATION DATE DATE iREMITTED AMOUNT <br /> 27 <br /> } D I ¢ <br /> FEE LAS SLI S ., <br /> LESS - .w- ..c..- ;s�.r• _ �' -,.,.,�.�e,..,- -w.�..- ". .....- ...-...-r --.� �.- <br /> �,,..� ._...,...P_RORATI.ON_..:...�.:. _-y.sti.,..n�i,-.a:.....- -•.ate`"'-<-r-...iww".r .•--.r. --�-.,"-$«�— -- <br /> PLUS UJ <br /> PENALTY <br /> r OTHER ( I ! <br /> r <br /> OTHER <br /> c ed by Uate Receipt No. ', Permit No. y Issuance Date 1 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br /> 1 <br />