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....... <br /> _— <br /> Applications Will 19e Processed When Submitted Properly <br /> APPLICATION Q <br /> y (Far Non-Transferable,Revocable, and Suspendable) SEPTAGE r <br />" ENVIRONMENTAL HEALTH PERMIT q # <br /> LIQUID WASTE <br /> Application is er y made to carry o business in the jurisdictional area of the San Joaquin Local Health District <br /> G 1 Address r <br /> N Business Name (DBA) o <br /> y Address <br /> a Owner <br /> I <br /> ll lll' <br /> J Firm Partners, Addresses and Telephone Number llr .............. <br /> Emergency Telephone No. <br /> 0. Business Telephone No. <br /> .J Contractor Licence No. i Title A/ Date <br /> �Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Intormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (F <br /> OR o aACSH VEHICLE) <br /> For July 1, June 30, 19 <br /> Description(Make/Yr.,Color) CAL. Licc-se Renewal No. q <br /> Serial No. CAL. License No. <br /> i <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> a_ 1 <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3_ ❑ PERCOLATION TEST R.S.Or_R.C.E.No. ti <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT J <br /> Job Address/Location 077l <br /> Address 4 <br /> Owner ❑ LEACHING FIELD ❑ SF PAGE".PITT , ❑ PACKAGEPLANT <br /> ` ❑ SEPTIC TANK ❑ CESSPOOL ❑ OTHER <br /> �f. <br /> C1 PERMANENT ., -❑ TEMPORARY.❑,NEW E PAIR <br /> � ---. <br /> I 5. C3CHEMICAL TOILETS For July 1;- June 30, 19 <br /> Type Construction Disposal Site <br /> l Equipment Storage/Cleaning Location(s) <br /> k No. of Units fi <br /> f 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <, <br /> Where Certified <br /> Operator Name <br /> k Plant Location * <br /> No. Units Served � <br /> Plant Capacity f <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 ki i <br /> ❑ More Than 1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., r ' 4 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. f R Lam. <br /> r <br /> i I hereby certify that I havefp pared thisapplication and that,the work will done.-in accordance with San Joaqui County <br /> ordinances, state laws, and rules and re lations of the San Joaquin Local HealtY�District. s ` <br /> APPLICANT'S SIGNATURE X "` <br /> f � ` <br /> tFOR DEPARTMENT USE-ONLY �. <br /> } _ ,.— nue <br /> 31 <br /> REMIT <br /> Fee IS DUB: ❑ ANNUALLY ' ❑ P,ER;UNIT 1 - El PER SITE�T❑ EA�H�" ��'January 1 &Received By January 31 July t 8 Receive y July <br /> 4 T REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE ~EXPLANATIONS <br /> BILLING <br /> DATE REMITTED AMOUNT <br /> I 4 r <br /> FEE - ,� t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> t Issuance Date Mailed Delivered <br /> Permit No. <br /> Date Receipt No. <br /> Received by 1501 E.HAZELTON AVE.,P.O.Box 2009 5TOCKTON,CA 95241 <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH-PERMIT/SSERVICES ,. ��✓�>�n. „x—� <br />