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Applications Will Be Processed When Submitted Properly Completed. vesure 1o ,7tgfr 1low•"r•N <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendabie) SEPTAGE <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i9b hereby made t ca on business i th 'uris tional area of the Sa¢IJ�oaqui 1Health-District alh District <br /> Address <br /> y Business Name BA) r ��_ <br /> Address77 <br /> a Owner <br /> J Firm Partners, Addresses and Telephone N bers <br /> Eli. Business Telephone No. Emergency Telephone No. <br /> a ; Z Z�09 <br /> Contractor Licence No. Date 3 <br /> L Applicants Name (Print) } �'2 Title <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, v June 3019 Disposal Sites <br /> Description(MaK41Y�.t-Colbr)- I CAL. Lic-nse Renewal No. <br /> 11 CAL. License No. <br /> Serial No, <br /> Capacity Gal.,Weights & Meaas]u�res No, y <br /> Equipment Parking Address - '(s# <br /> 2. 11 PUMPER YARD Jif <br /> For July 1, June 30, 19 Tril ; <br /> No. of Vehicles Stored li Noi <br /> 1 <br /> No. of Chemical Toilets Stored <br /> ' ! �/ i 1 <br /> 3. ❑ PERCOLATION TEST 1 i"R.S.or R.C.E. No. to <br /> R.S. or R.G.E. Name _ { <br /> Test Location M <br /> 1 I* 4 ' Test Date/Time <br /> 1, <br /> 4. ❑ SANITATIONLPER7MIT1 rI ` <br /> Job Address/Loc ioQ E <br /> LLyc Address <br /> 0 <br /> pner ❑ PACKAG PLANT x <br /> SEPTIC TANK`' ❑ CESSPOOL QyeE HING FIELD SEEPAGE PIT <br /> ©/ ❑ REPAIR 00 THER <br /> ❑ PERMANENT ❑ TEMPORARY NEW <br /> I <br /> '1"— <br /> "— <br /> 5. 11 CHEMICAL TOILETS For July.1, <br /> -June 3D, 19 <br /> Type Construction ; Disposal Site <br /> �Equipmento <br /> Stragcation <br /> (s) <br /> Locatios) <br /> No. of Units <br /> ne 3D, <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -Ju1'9"' Where Certified <br /> E. � <br /> 1 Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> Ft <br /> Sq. . <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 _ <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <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, and rut d re lati ns of t Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> PER C] PER SITE ❑ EACH ❑ January 1 &Received By January 31 .C] July 1 &Received By July.31 <br /> PE <br /> Fee Is Due: ❑ ANNUALLY' ❑ REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS F <br /> PENALTY .� <br /> OTHER <br /> OTHER <br /> t-79- <br /> ance Date Mailed elivered <br /> Received by_ Date <br /> Receipt No. Permit No. Issu <br /> _ 1601 E:HAZELTON AYE.,P.O.Bo=,2009 STOCKTON,C 55201 <br /> APPLICANTS R£TURN ALL COPIES TO: ,__ENVIRONMENTAL HEALTH PERM I /SERVICES„ // � <br />