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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. I <br /> APPLICATION <br /> (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-L�I�Health District �a l <br /> _Powe1 6 ckoe �InG, Address.�3 Hi <br /> y Business Name (DBA) <br /> z Owner �� M V ¢�!� Address <br /> a , � 77dj <br /> Firm Partners, Addresses andTelephone umbers Emergency Telephone No. <br /> Q. Business Telephone No. <br /> a <br /> Contractor Licence No. � <br /> IyDate <br /> Applicants Name (Print) on Frieda- S�`A IG 15 Title <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. F-1 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,19 i Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License 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 Stored V E <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Dale/Time <br /> 4. ❑ SANITATION PERMIT <br /> f 7 /6 So zr/or, <br /> i Job Addr..e-sus/Location 3 t S o w r e yl C 8716 J7 <br /> _ / `�/ G 1SS �Ie, ta- Address <br /> Owner <br /> ® LEACHING FIELD 0 'SEEPAGE PIT ❑ PACKAGE PLANT <br /> ® SEPTIC TANK ED] CESSPOOL ❑ OTHER <br /> ❑ PERMANENT C] TEMPORARY ❑ NEW 11 REPAIR <br /> 5. 11 CHEMICAL TOILETS-For July 1,-IJune 30, 19 <br /> Type Construction 1 Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location ► <br /> No. Units Served <br /> Plant Capacity <br /> 7. 11LAUNDRY For July 1, -June 30, 1'9 <br /> SIZE: ❑ Less Than 1,000 Sq- Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i 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 Sad Joaquin cal Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> 4 FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑- ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION - <br /> BASE DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PROBATION <br /> PLUS — <br /> PENALTY ' <br /> OTHER <br /> OTHER <br /> _ � <br /> � 4 `7 issuanc Date Mailed D Ilvered <br /> Date Receipt No. Permit No <br /> Received by - 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTO ,CA 95201 <br /> i APPLICANT—RETURN ALL COPIES TO f�ENVIRONMENTAL HEALTH PERM ITISERVICES �.. �j�'I <br />