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Applications Will Be Processed *,e, n Submitted Properly Completed. Be Sure To Sign The AppIICatlon.: <br />1 <br />APPLICATION I <br />(For Non -Transferable, Revocable, and Suspendable) <br />SEPTAGE <br />4 <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Applicata !Sher by m et 6rry o usin Ss the Jurisdictional area of the S n Joa LOC al:Fjealth 'strict /% <br />Address. <br />[ <br />Busines a (08A C' < <br />rn <br />aOwner Address <br />S2 Firm Partners, Addresses and Telephone Numbers _3 <br />Emergency Telephone No. <br />a No. <br />Business Telephone <br />4t, <br />_j Contractor Licence No. ,�� _ —Date <br />Title J z.- <br />—1 <br />L Applicants Name (Print) <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) CAL. License Renewal No. <br />CAL. License No. <br />y <br />Serial No. <br />Capacity Gal., Weights & Measures No. -- <br />- <br />Equipment Parking Address <br />2. ❑ PUMPER YARD r <br />y <br />For July 1, June 30, 19 <br />} No. of Vehicles Stored <br />y , No. of Chemical Toilets Stored <br />3. ❑ PERCOLATION TEST. R.S. or R.C.E. No. <br />I : R.S. or R.C.E. Name <br />Test. Date/Time <br />Test � Location <br />d6�� (,)1j`- <br />q. SANITATION PERMI 1111 <br />Job Add res ocati In <br />Owner Address <br />�� , <br />55 <br />PKEPTIC TANK ❑ CESSPOOL �-GEACHING FIELD ❑"SEEPAGE PIT ❑PACKAGE PLANT � <br />! <br />! 0-*hMANENT ❑ TEMPORARY € Q,D*w ❑ REPAIR ❑ OTHER <br />s. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Constructlon Disposal Site <br />Equipment Storage/Cleaning Location(s) <br />Nd. of Units <br />t 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />e Where Certified -- <br />Operator Name I <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 />I hereby certify that I have prepared this app ication and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, an rules a d regula of a San Joaquin Local Health District. <br />1 <br />` APPLICANT'S SIGNATURE <br />R <br />Fee Is Due: ❑ ANNUALLY <br />BASE <br />FEE ^'1 <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />FOR DEPARTMENT USE ONLY <br />❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By, <br />81LLING REMITTANCE <br />EXPLANATION DATE DATE REMITTED <br />137 <br />31 ❑ July 1 & Received By July 31 <br />REMIT <br />AMOUNT DUE CHECKED <br />AMOUNT <br />KRiveal by Date Receipt NO. """ CA 95201 <br />1801 E. HAZELTON AVE.,P.O, Bo <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES x 2008 STOCKTON, <br />.-� <br />