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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatyi D-�s hereby made to carryon siness in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) .1[Sta�k nn Incc �- 1� 2 2A- Address ?2.3 W E I rr —' L u <br /> zOwner�y Wv- AQ Address PU lam. Ox 1O03G <br /> Firm Partners,Add sses and Tele hone Numbers T' >1 to 7-z-Z ,� '`� _12'W t.K-L p Z J&466 18 <br /> aBusiness Telephone No. ����'-Gl�� Emergency Telephone No. <br /> 11 Contractor Licence No. <br /> Applicants Name (Print) 2 Title 1 f- Date - �Z 3--&.F, <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. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No o Chemical Toilets Stored <br /> 3. )Q PERCOLATION TEST <br /> -R-A er R.C.E. Name 1l�rr'+ �t to Z Z,4 R.S. r R.C.E.No. <br /> Test Location -SnFk/J ,jE &%,%o 1? d Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction 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 <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 Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepar application an at thew rk will be done in accordance with San Joaquin County <br /> ordinances, state I s, an nd regulations of San Joa Local Health District. <br /> APPLICANT'S SIGNATURE. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> $' AMOUNT <br /> FEE j <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1991 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />