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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION lei 7 <br /> (F\ m-Transterable,Revocable, and Suspendable) SEPTAGE r <br /> ENVIRONMENTAL HEALTH PERMIT 6 <br /> LIQUID WASTE -4- <br /> Application I$her b��yJJmad��e to carry onbusiness in the jurisdictional area of the SarlJoaquLocal Health District �e l <br /> r Business Name (DBA)- "Address <br /> Owner -.z..�.4� . Address _ ----- <br /> Firm Partners. Addressgs and Telephone�Nuurrl <br /> iBusiness Telephone No. ,r Emergency Telephone No. . <br /> Contractor Licence N.C. DRi -arm _ J <br /> L Applicants Name (Print) � y -�L�-�i Title -G�� �R Date 9' ��b <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 DO <br /> Description(Make/Yr.,Color) ' <br /> Serial No. CAL. License No. _ CAL. License Renewal No. <br /> Capacity Gal.,Weights& Measures No. <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. <br /> Test Location _ Test Date/Time _ <br /> 4. ❑ SANITATION PERMIT <br /> _Job Address/Location Y" e GZ;/ �� ! '� xi•I —F <br /> ':Owner L-,o_!��J �� Address es-r -4" <br /> ❑ SEPTIC TANK Q CESSPOOL EACHING FIELD LISEZA&DE PIT ❑ PACKAGE PLANT <br /> A PERMANENT ❑ TEMPORARY O NEW EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 ' <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locatiofl(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Pl..nt 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 /> `c- <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, slate laws•and rules and regulatigs of San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT "D PER SITE ❑ EACH ❑January/d Received By January 31 ❑ July 1 d Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> I <br /> PRORATION t ' <br /> PLUS <br /> PENALTY <br /> OTHER \ <br /> OTHER <br /> Do <br /> Received by Date Receipt No. Permit No. lnqbnce D le Mailed Delivered rY! <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTO AVE.,P.O.An,2d09 STOCKTON,CA 95901 �Y <br />