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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION I-V <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> f. Applicatio�l iser y made t�carry onpusiness in the jurisdictional area of the San Joaquin Local Health District "r� <br /> F. r U �J Orr)S Jd (i S -7y'— Address P <br /> H L�oX �/ r ST f�iV 4 Sir L7 <br /> Business Name (DBA} <br /> Z Owner Address <br /> i t <br /> L) Firm Partners, Addresses"and Telephone Numbers <br /> EL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. . f� f� •7 <br /> Applicants Name (Print} r <br /> Title SZ W �Q!' Date—. <br /> Please check Applicable Category (1-7)and Fill in the Required Information VOW <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> i For July 1., June 30, 19 Disposal Sites J <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights &Measures No. <br /> R <br /> K Equipment Parking Address s►• <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> t 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 Test Date/Time <br /> 4. 0 SANITATION PERMIT <br /> Job Address/Location AJ Y • <br /> Owner �L Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT , <br /> 00 PERMANENT ❑ TEMPORARY X NEW ❑ REPAIR ❑ OTHER i <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction , . Disposal Site <br /> No. of Units i Equipment Storage/Cleaning Locations} <br /> 6. ❑ PACKAGE TREATMENT PLANT E For July 1, -June 30, 119 <br /> Where Certified <br /> I Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 /> a <br /> a <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> iordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> C�I <br /> F <br /> I L <br /> FOR DEPARTMENT USE ONLY <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 E.Received By January 31 ❑ July 1 &Received By July 31 <br /> I _ REMIT <br /> BASE EXPLANATION BILLING REMITTANCE. $ AMOUNT DUE CHECKED <br /> DATE DATE- REMITTED AMOUNT <br /> F. <br /> FEE <br /> t LESS <br /> PRORATION <br /> PLUS s <br /> PENALTY <br /> 1 . <br /> OTHER <br /> 1' <br /> OTHER--------------- <br /> - <br /> r. -�9 tqg 1 13 -71 <br /> Received by - Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> fi <br /> APPLICANT-RETURN ALL COPIES TO: <br /> ENVIRONMENTAL HF�LTH PERMITlSERVICES 1661 E.HAZELTON AVE.,P.O.Box 2008_ STOCKTON,CA 95201 <br /> �►►,a r 1.�XQ F�Lt'�-b� a e GL jvo Cltic�d- (u-u lue9� <br />