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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> a' APPLICATION <br /> w (For Non-Transterable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ereby made o carry on business in the juris ictional area of the S�ap Joa uin Local Health�Disst t <br /> Business Name A) %- Address_ V � 7G rJ <br /> z Owner_ -��� � 4�"--,t �— Address Q <br /> V <br /> Firm Partners. Addresses and Telephone Numbers l ti <br /> 115- <br /> CL <br /> Business Telephone No. - `�` `� Emergency Telephone No. <br /> Contractor Licence No. Id <br /> � <br /> Applicants Name (Print) Title Date S` �b <br /> Please:check ApplicableCategory (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, .ire " "June 30, 19 Disposal Sites <br /> Description''(Make/Yr., Color)1%4 <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity' Gal.,Weights & Measures No. <br /> Equipment Parking Add ressN <br /> 2. ❑ PUMPER YARD d- <br /> For July 1, June 30, 19 pp <br /> No. of Vehicles Stored y <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 1 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> I <br /> Job AddresslLocati , <br /> O er Address <br /> PTIC NK ❑ CESSPOOL ACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> L1 PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 71 <br /> Type Construction Disposal Site f"€/ <br /> 1 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 J <br /> Operator Name t ( t Where Certified <br /> Plant Location <br /> Plant Capacity_ i No. Unils+Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000.Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r <br /> I hereby certify that I have._prepd_red this application and that the work will lie.done in ac rdance with San Joaquin County <br /> f ordinances, state laws, and rules, nd regulations,of- a `oaquin-L�al Health Lf}4&tric . <br /> I_ APPLICANT'S SIGNATURE X f� <br /> fly <br /> FOR DEPART NT USE NLY <br /> Fee Is Due., ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH anuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING RE TTANCE $ AMOUNT DUE CHECKED <br /> DA E DATE REMITTED ¢' AMOUNT <br /> FEE T� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6061 <br /> Received by - Date _ Receipt No. ermit No, Issuance Date Mailed 11 Del. Bred <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />