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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r (For Non-Transferable;Revocable, and Suspendable) SEPTAGE <br /> f ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> II <br /> Application is:hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District,l; <br /> A s <br /> ryBusiness Name Address" F <br /> (DBA}_ !Q •�L `"�' ,, o ... . <br /> aOwner . - _-•JZ' Address it. <br /> Firm Partners, Addresses and Telephone Numbers Iv <br /> CL Business Telephone No. � � � ti Emergency Telephone No. <br /> :.j Contractor Licence No. <br /> Title -�� Date <br /> L Applicants Name (Print) <br /> 14 Please check Applicable Category (1-7)and Fill7in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> JY <br /> 11 <br /> For July 1, June 30, 19 <br /> Disposal Sites - <br /> Description(Make/Yr., Color) <br /> Serial No. CAL, License No. CAL. License Renewal No. i <br /> ti I. <br /> 1� Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address . <br /> 2. ❑ PUMPER YARD r <br /> For July 1, June 30, 19 i <br /> No. of Vehicles Stored i r <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> i R.S. or R.C.E. No. <br /> III R.S. or R.C.E. Name _ j <br /> !j Test Location Wiest-DateGTime <br /> I� 4. ❑ SANITATION PERMIT <br /> { % <br /> Job Address/Location <br /> Owner Address <br /> I II <br /> li✓f SEPTIC TANK ❑ EA <br /> CESSPOOL CHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ` ❑ PERMANENT ❑ TEMPORARY 11NEW ❑ REPAIR ❑ OTHER <br /> ' l! <br /> li 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> ! t Disposal Site <br /> � Type Construction � � p ., _ <br /> Equipment Stora a/Cieanin Locaiion(s"} - n <br /> Ij No. of Units i - 9 9 <br /> 6. ❑ PACKAGE TREAT MENT PLANT:-, For July.1,-June 30, 19 <br /> �e { <br /> Where Certified.., <br /> Operator Name <br /> Plant Location <br /> ii Plant Capacity t No. Units Served- <br /> .. ; <br /> z r' <br /> ;l 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than Ib00 Sq. Ft., ❑ More Than 1,100 Sq. Ft. FNM ��..tk t I <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that_[,,haue_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 San Joaquin Local Health District. <br /> 5 APPLICANT'S SIGNATURE X _ 'I <br /> FOR DEPARTMENT USE ONLY rIi <br /> II Fee Is Due: ❑ ANNUALLY ❑ PER.UNIT,} ❑ PER SITE 11anuary <br /> EACH t ❑ Y 8,Retei ,B,yFJBnuary 35 T ❑ Jul ,1 R Received By July 31 <br /> t f 1 '� i REMIT <br /> IS BASE EXPLANATION BILLING TANCE $ EDAMOUNT DUE CHECKED <br /> DATE DAT REMITT ,! AMOUNT ` <br /> f <br /> ' FEE <br /> LESS ...y 7, 1 --y A' <br /> t - <br /> PRORATION <br /> PLUSr- <br /> PS PENALTY <br /> �! OTHER <br /> OTHER.. <br /> Permit No. suane Dat <br /> Received by Date Receipt No. <br /> Mailed Delivered Lw <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTii`PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> �t <br />