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Applications Will Be Processed When Submitted Properly Completed. BeSureTosign 1neAPp11c0uv1F. <br /> APPLICATION <br /> r (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati is hereby ma to c rr�r o usine s. the' nsdictional area of the n Joa in Local Health Dist 'ct , e <br /> R y Busine Name (DB ) Address— <br /> Address <br /> d <br /> j Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. x <br /> a �'J <br /> Contractor Licence No. Co <br /> L Applicants Name (Print) <br /> Title Date 07 A3 <br /> Please check Applicable Catego (1-7)and Fill in the Required Information <br /> 1: ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE), <br /> For July,i, June 30, 19 ' Disposal Sites <br /> . <br /> Description•(Make/Yr-,'Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> . n <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> i <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.a.E: No. <br /> Test Location Test Date/T'IIn1e <br /> 4. ❑ SANITATION PERMIT <br /> Jab Address/Location lkyfl? -Z <br /> ,O�w�ner ,,,� ddress _ t� <br /> u�SEPTIC TANK ❑ IIsCESSPOOL LEACHING FIELD �EPAGE PIT ❑ PACKAGE PLANT <br /> E�ERMANENT ❑ TEMPORARY ❑ NEW 1:1 REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> I Equipment Stora Storage/Cleaning Location(s) <br /> No. of Unitsg g " <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 f ` <br /> 1 Where Certified <br /> Operator Name <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 /> ,.- . Narrns�oo�lrler��srnartl�:'rilR�F�4y'�Ir�tilil���f�'i�f�k�4fr�fG�t�fi•5�1Er�ieeQ}.��Q�t �lr�i��o-n <br /> 11A1�(flilRt��11t9r�4141i�A�l[k1E�lll�tlhtl'�VF7f'k9It�YI1'Si �BtiDAl$Ml�`t�{.�I!!IffAllia_' .. .i ; ti. <br /> t4�srt e.s*rrsa 9iniiry or �nb,ca rae3ir� stir*+aiarH certifies the follow "fi ifyYt ttn#fte i�trrril iicenftheviarkForwfliChthis{iermAis'issuetl.i ita'+I <br /> & y,p>ar�ns.suJ�actle r.nrkmara:s�ral�saEian laws at CatitorRia" <br /> 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, a rules an egu tions of the San Joaquin Local Health District. <br /> APPLECANT'SSIGNATURE'X <br /> `T- <br /> r " r FOR DEPARTMENT USE ONLY <br /> By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT C1 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiJeRdEMIITuly 31 <br /> R i BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 a 7 <br /> Received by Date Receipt No. Permit No. I suance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 �STOCKTOfj,CA 95 '7� <br /> ll �ij+�JWf ��i <br />