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Applications Will Be Processed When Submitted Properly Completed. Be Sure To So S g he Application. T <br /> APPLICATION <br /> (For Non-Transferable;'-'Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> LIQUID WASTE <br /> Application is her by made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name {DBA)- �� T i.ni��. Address S7� J, <br /> aOwner ( Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. I Emergency Telephone No. <br /> a Contractor Licence NO, - <br /> a Applicants Name Printf !-•tit (.�r�L'Y <br /> L ( --• - Tltle .Ol�r1i�� , --Date.,..? .2 -g'/ � <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-.Z- .f- `Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. "j <br /> CAL- License No. CAL- License Renewal No. <br /> Capacity Gal.,Weights Sr Measures No. <br /> Equipment Parking Address V <br /> 2. ❑ PUMPER YARD } <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> q I <br /> No, of Chemical Toilets Stored - <br /> 3. ❑'PERCOLATION TEST r . <br /> R.S. or R.C.E. Name t - '� R.S. or R.C.E.-No. <br /> ,Test Location I t fTest Date/Time <br /> 4.SANITATION PERMIT f --- l <br /> Job Address/L cftion ; _. (—rte „ <br /> T !/ <br /> Owner Address *t <br /> 11SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PAC AGE PL NT } <br /> ❑, PERMANENT ❑ TEMPORARY NEW ❑ REPAIRt ❑ OTHER <br /> 5. E] CHEMICAL TOILETS' For July 1, -June 30, 19 r 4 W <br /> Type Construction Disposal Site f t t f d <br /> No. of Units Equipment Storage/Cleaning Cocation(s)' I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 .- <br /> Operator Name t .Where Certified <br /> Plant Location > t <br /> Plant Capacity No. Units Served (' f <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 /> r � s <br /> I hereby certify that I have prepared this application and that the work will,be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the Sari Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> - <br /> FOR DEPARTMENT,USE ONLY <br /> Fee IS Due: ❑-ANNUALLY_ _❑ PER UNITS ❑ PER.SITE ❑ EACH -❑ January I &Received By January 31 ❑ July 1 &Received By July 31 <br /> T1 BILLING ` REMITTANCE — REMIT <br /> BASE EXPLANATION S AMOUNT DUE CHECKED <br /> --- _t i - DATE - DATE ;_ - REMITTED- - AIv10UNT <br /> t <br /> 1W /oil <br /> LESS F <br /> PRORATION <br /> r <br /> PLUS <br /> . . PENALTY <br /> OTHER <br /> 3 T <br /> i OTHER..- <br /> Received by Date {;Receipt No Permitt}No- ' Issuance Date Mailed Delivered' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,-P.D.Box 2004 STOCKTON.CA 95201 <br />