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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 /> A Iication is ber made to carry npusiness in the jurisdictional area of the San Joa uln Local Health Distri t <br /> Or �]1r{-ifC<7jTj� <br /> Business Name (DBA). C7h;eI h 14CKh iD A _ Addresc''Ksss— f r� 6 Qo' ' a <br /> `z Owner � �V I S '� Address <br /> % � - <br /> Firm Partners, Addresses and Telephone Nu'mbers df �7e-' 16 <br /> a <br /> CL Q. Business Telephone No. ZI-7' � 1 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) u <- Title ��N� 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 ��' �I]isposal'Sifes:l: <br /> Description(Make/Yr., Color) — - -CAL. License Renewal No. <br /> Ji <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weig,�tsJ&,Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD *, , ,��1 z C'- <br /> For July 1, June 30<19 <br /> No. of Vehicles Stored - Q � <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name <br /> R.S.or R.C.E. No. <br /> Test Location Test Date/Time t 1 <br /> 4. ❑ SANITATION PERMIT <br /> f <br /> 'Job Address/Location <br /> �14-hAddress � <br /> Owner" fl -- <br /> s��LF�ACHING�FIELID ❑ SEEPAGE PIT_ ❑ PACKAGE PLANT❑ SEPTIC�"AfTK ❑'CESSP�Lw..+ ;� <br /> ❑ TEMPORARY- ❑` NEW REPAIR OTHER <br /> ❑ PERMANENT .. <br /> 5. ❑ CHEMICAL TOILETS For July 1, -Jun-e30",.19 <br /> Type Construction Disposal Site - <br /> be >.-__ 1 <br /> No. of Units Equipment Storage/Cleaning Locations)° t _ } <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,}((19,- ! �r <br /> E F WhereCertitied�-- <br /> Operator Name I - <br /> Plant Location <br /> Plant Capacity ; No. Units Served. 4 � <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., El More Than 1,000 Sq Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> } � . <br /> I hereby certify that I have prepared t s lication an that the work will be'done in accordance with San Joaquin County <br /> ordinances, state laws, and rules an ons of th an Joaqu o I Heaiih District.- k-. s <br /> APPLICANT'S SIGNATURE X .. ' <br /> FOR DEPARTMENT USE ONLY I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH.. ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> il <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> i <br /> FEE � {` <br /> LESS s <br /> PRORATION <br /> PLUS S i <br /> PENALTY t <br /> F - <br /> . -�.--OTHER-•--a+.-....-.-. �����.�.,��� +,+.. ;y,,. >�'�:� — _ � ,.. _ .� ._ <br /> Received by,—,_ Date Receipt No. Permit No. Issuance D e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:..�ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 '.5TOCKTON,CA <br /> --�"+ - <br />