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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 /> Application is hereby made to carry on business in the jurisdictional area of the San J aquin Local Health District <br /> mBusiness Name (DBA) LZ:e 'fzev�!fa Address y1 —�G�Z'- 'G� Yds <br /> i Owner CFz 44,3iT Address <br /> a <br /> J Firm Partners, Addresses and Telepho e Numbers <br /> aBusiness Telephone No. S Emergency Telephone No. <br /> Contractor Licence No. _ <br /> Applicants Name (Print) - • y�%� - � Title 46,r::a - Date j ;Jr� 4 <br /> Please check Applicable Category (1-7) and Fill in the Required Information s <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) r <br /> Serial No.� - CAL. License No. _ T CAL. License RbadWal 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 LocationTest Date/Time ' <br /> 4. SANITATION PERMIT _ _ <br /> Job Address/Location f- 4���v=T��� <br /> Owner . T N Address SG4�o <br /> SEPTIC TANK ❑ C SSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS 'Fo"uly 1,June 30, 19 V <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) I <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 prepared this application and that the work will be done in accordance with-San Joaquin County <br /> ordinances, state laws, and rules and rOulatiqns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑-January 1 &Received.ByJaouery 31 ❑ July 1 &Received By July 31 <br /> s,. - - - REMIT <br /> -bASE EXPLANATION <br /> BILLING 1 REMITTANCE $ C <br /> � AMOUNT DUE- CHECKED <br /> DATE - DATE-" REMITTED AMOUNT <br /> l FEE <br /> �+ <br /> LESS <br /> PRORATION - -- - - <br /> PLUS a <br />�- PENALTY LW <br /> OTHER .. <br /> OTHER <br /> �•' j�� Y <br /> f Received by s Date Receipt No. Permit No. lAsuanqh Dale Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />