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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> *^ (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE i <br /> Application jjs hereby made to carry o business in the jurisdictional area of the San Joaquin Local Health District , <br /> UF Business Name (DBA) 14,Iy/gw .Address <br /> z Owner..-t . .Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL CL Business Telephone No. _ - Emergency Telephone No. ; <br /> } <br /> � <br /> Contractor Licence No. <br /> Applicants Name (Print) v Title • Date :. <br /> Please check Applicable Category (1-7)and Fill in the Required I ormation <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 /> Far July 1';-'"" June 30, 19 <br /> No. of Vehicles Stored <br /> No, of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST t y <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 t <br /> Job Address/Location <br /> Owner,�� � �lvs�i4-�y Address S� <br /> .® SEPTIC TANK ❑ CESSPOOL LEACHING FIELD �. PIT ❑ PACKAGE PLANT w <br /> fig PERMANENT ❑ TEMPORARY 4WNEW REPAIR ❑ OTHER (51 i <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 0 ' <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 0 PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No, Units 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. <br /> €I� A{�A6RF€IFA��aI}? Ag$i�ff <br /> 3tsIFI1QAf(1€i �411t?ft1dl. w , mpoyanylcrson <br /> 1411-k #- <br /> t <br /> - os#tgap#�Ir.s n�flrlg p.'C. sub Gantt ctiy?g's: �tntclte ect f�na fi�a #n taw na 1 cenily that tilt the performance of work fQ�which this permit is issued,l shall <br /> mplb�persti Is su6j>wct 3b vrOr,mads comeiisatcon 4axsGalifotri.a, (. ;- •� <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and andreg tato of the,' a)Joaquin Hepith District. <br /> APPLICANT'S SIGNATURE X <br /> r <br /> L <br /> FOR DEPARTMENT USE ONLY <br /> e/- <br /> .Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ` <br /> REMIT <br /> BILLING REMITTA E $ <br /> AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE D REMITTED <br /> AMOUNT <br /> FEE r <br /> 4 l <br /> LESS <br /> PRORATION Alf <br /> PLUS <br /> PENALTY _ k, s y <br /> •a ` � 1 � --ti of-w � .� � Y- 1 <br /> OTHER' '� .; .t"-: <br /> \A <br /> i t <br /> OTHER <br /> Received by - Date ,Receipt No. Permit No. - is uance 8a a Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES" '1'1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 . <br />