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_ Ow <br /> Applications Will Be Processed when Submitted <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.jurisdictiona area o the San Joaquin Local Health District; + , <br /> Addr <br /> NBusiness Name (DBA) Address <br /> x Owner <' <br /> a <br /> J Firm Partners, Address and Telephone Numbers Emergency Telephone No. <br /> CL Business Telephone No. <br /> a - <br /> Contractor Licence No. ,.. .- Title s Date l <br /> Applicants Name 'Ll il <br /> Please check Applicable Category(1'-7)and Fill in the Required Information-1, €' <br /> i }, [3 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) w - <br /> June 30,19` - _ - r Disposal Sites - <br /> For July 1, - <br /> Description(Make/Yr., Color) CAL. License No, CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> I 2, ❑ PUMPER YARD <br /> II For July'1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored_ y <br /> I 3, ❑ PERCOLATION TESTR,S, or R.C.E.No. <br /> j R.S.or R:C.E=. Name Test Date/Time <br /> Test Location <br /> i q. ❑ SANITATION PERMIT�ya We en <br /> Job Address/�Lo­ <br /> en <br /> n Addr ss <br /> ( Owner s ❑ PACKAGE PLANTSEPTIC T ❑'C SSPOOL " f LEACHINWr G FIELD ❑ SEEPAGE PIT El OTHER a <br /> PERMANENT <br /> ❑ TEMPORARY ,04 NEW ❑ REPAIR <br /> S- ❑ CHEMICAL TOILETS For.July 1,-June 30, 19 <br /> Disposal Sife <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> r ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ,: <br /> g, Where Certified <br /> Operator Name - <br /> I Plant Location <br /> ( No. Units Served <br /> Plant Capacity ; <br /> l 7. ❑ LAUNDRY*For July 1, -June 30, 19 <br /> ❑ Less Than 1,000 Sq. Ft.,, }❑ More Than 1,000 Sq. Ft. k ,- <br /> [a SIZE: . <br /> ElDRY CLEANING, Chemicals Used/AmounVMo. <br /> . .. -- . <br /> ll <br /> done <br /> I hereby Certify that I hav re area re is lapolic t o hem that the work Joaquin Local lHeaeth District. <br /> ccordance withan Joaquin County <br /> ordinances,state laws, a rul a <br /> APPLICANT'S SIGNATURE X,. <br /> t FOR DEPARTMENT USE ONLY <br /> PER SITE ❑ EACH ,❑ January t &Received By January 31 ❑ Jury 1 8.Receive REMIBy TuIY 31 <br /> + Fee IS Due: ❑ ANNUALLY ❑ PER UNIT: - $ AMDUNT DUE CHECKED , <br /> } BILLING REMITTANCE :- • V _ i, <br /> BASE jI EXPLANATION —DATE DATE REMITTED { AMOUNT <br /> FEE-.. <br /> LESS 1 r <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i OTHER - <br /> J <br /> OTHER <br /> u V <br /> Issuance Date ailed Delivered <br /> Permit o. r. <br /> Date i Receipt No- _ _ - -Box 2009 STOCKTON,CA 95201 <br /> Received y ! _ 16d1 E.HAZELTON AV ., <br /> APPLICANT—RETURN ALL COPIES TO: `ENVIRONMENTAL HEALTH PERMITISEflYICES <br />