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Applications Will Be Processed When Submitted Properly Completed. Be Sure Sign The Application Id <br /> 3o I <br /> _ APPLICATION <br /> IF, ,on-Transferable,Revocable, and Suspendable. SEPTAGE <br /> ENVIRONMENTAL:HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to harry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (011A)I� ALL e9'rl Address 1�.Jp� 73 ^rZ Z4 9 617—cy-k <br /> Owner Ole Address _ <br />:i Firm Partners,Addresses and Telephone Numbers _ Z <br /> t Business Telephone No. ys_s,�� "n-'�'� ,_ Emergency Telephone No. <br /> i <br /> Contractor Licence No. , <br /> L Applicants Name (Print) A„�., r�2>/ J Title 0.w Nth Date <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, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL.License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights&Measures No. _ W <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD - <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.C.E.No. r <br /> Test Location Test Date/Time _ <br /> SANITATION PERMIT <br /> Job Address/Location /�0\ `l i• t� <br /> Owner �12. �o�—� Address - 7-,,v -Tilwey <br /> Ia-$OPTIC TANK ❑ CESSPOOL 21'CEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 0 TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-Jyne 30, 19 <br /> Type Construction t '4 Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1.,-June 30, 19 <br /> Operator Name Where Certified (n <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 Thar 1,000 Sq. Ft. , ' - <br /> ❑ DRY CLEANING,Chemicals Used/Amaunt/Mo. <br /> •• J <br /> 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 rulesan re ul 'ons o t e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> .y FOR DEPARTMENT USE ONLY . <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ eACH t,❑ January 1 d Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANC S REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DAT REMITTED <br /> 5 _ <br /> AMOUNT <br /> FEE <br /> LESS j <br /> PRORATION <br /> PLUS 2 0 <br /> PENALTY / <br /> OTHER <br /> i. <br /> OTHER ' <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Be.2009 STOCKTON.CA 95201 - <br />