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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> � Z41 APPLICATION <br /> ,. 4. (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 w <br /> Y. , _.. , -.F <br /> w Business Name (DBA) <br /> Add <br /> j .r. f.f - <br /> *t I1G <br /> D <br /> a Owner Address <br /> E , <br /> 1 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No.r G Emergency Telephone No.. s <br /> Contractor Licence <br /> Title Date <br /> LApplicants Name (Print) tic a= r^ <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 " Gal.,Weights &Measures No. <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 Store-d­­ <br /> 3. <br /> tored3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E:Name R.S. or R.C.E. No. <br /> Test Location <br /> ca4ion Test Date/Time <br /> 4. SANITATION PERMIT- - y <br /> Job Adder WLocati n is <br /> Owner �`[- Address <br /> SEPTIC-TANK V��•CESSPOOL .LEACHING FIELD 11 SEEPAGE PIT PACKAGE PLANT 'f- <br /> ❑ PERMANENT .,�❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER ,, - <br /> 5.'' ❑ CHEMICAL TOILETS For'July 1,Y.-June 30, 19 ^ <br /> Type Construction f y $,Y Disposal Site <br /> No. of Units �. , Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE:TREATMENT PLA NT''For July 1, -June 30, 19 <br /> Where Certified <br /> Operator.Name S <br /> .Plant Location i J <br /> Plant Capacity - No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 149 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft;, More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> � k <br /> `l hereby certify that I fiav�}prepared this application and that the work will be done in accordance with San Joaquin County <br /> P } ordinances, state laws land ruies and T gulation of the an Joaquin.Locai Health District: - <br /> 114 IL <br /> APPLICANT'S SIGNATURE Xy� f <br /> V 1Of <br /> FOR DEPARTMENT USE ONLY r - <br /> t Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdE13Y July 31 <br /> IT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED " <br /> DATE DATE REMITTED AMOUNT <br /> FEE q`^-'B <br /> LESS - <br /> PRORATION '' <br /> PLUS <br /> PENALTY + <br /> OTHER r <br /> OTHER <br /> eP— <br /> ` <br /> Received by ai: <br /> nate Receipt No. Permit No, Issuance Date Ma d Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P. a 2009 - STOCKTON,CA 95201 <br />