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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign ineAppuaauvn. <br /> APPLICATION <br /> 4 (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h,�reb made to cam n business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) I �' , �"�11.� AK Address <br /> I- Owner Address- y <br /> a <br /> 9 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness:Telephone No; Emergency Telephone No. <br /> Contractor Licence No. �� —" s Title Date <br /> Applicants Name (Print) xZar <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i <br /> For July 1,--:-.-June 30; 19 - Disposal Sites - <br /> Description(Make/Yr.,Color) <br /> CALLicense No. <br /> CAL. License Renewal No. <br /> Serial No. . ! ; 1 <br /> Capacity Gal., Weights R Measures No. � l <br /> Equipment Parking Address i l <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 .` i 1 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST" <br /> R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location } ' -47 Test Date/Time <br /> =� <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Own y, 1 - Address <br /> ❑ CESSPOOL 's EACHING FIELD ❑ SEEPAGE ❑ PACKAGE PLANT <br /> SEPTIC TANK ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR <br /> y <br /> 5. ❑ CHEMICAL TOILETS For Ju`yyt,;,June 30, 19 <br />�. Type_Constructioni <br /> --Disposal Site <br /> No. of Units 1 Equipment Storage/Cleaning'Location(s) T <br /> 6. 11 PACKAGE TREATMENT PLANT For Juyy;_June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ElLAUNDRY For July 1, -'June 30, 19 , <br /> SIZE: OL Less Than 1,000 Sq Ft., ❑ More Than 1,000 Sq. Ft. <br /> s <br /> ❑ DRY CLEANING, Chefnl"cals Used/AmauIlUMo. <br /> 1 I <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 r latio sof the San Joaqu n Local Health Diptract: <br /> APPLICANT'SSIGNATURE X <br /> ( a FOR DEPARTMENT USE ONLY <br /> t *,:' t <br /> Fee Is Due ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ©.EACH j [I January 1 &Received By January 31 ❑ July 1 &Received B'ylTuly 31 <br /> BILLING: REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION IDA7E i DATE REMITTED AMOUNT <br /> I FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> , <br /> PENALTY' . ' <br /> OTHER F <br /> OTHER <br /> J <br /> Recei t No. Permit Issu rice ate Mailed Delivered <br /> Received"by Date" P <br /> "APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELT0 AVE.,P.O.Sox 2009 STOCKTON;CA 95201 <br />