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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 /> 3 LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District _ <br /> Bosiness Name (DBA) �- Address ►S• ! z�, <br /> i Owner Address—�,__ Jd�.�l L'� <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> C6 <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) �T L, ��f�r✓� _Title 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 Disposal Sites i <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. V <br /> Equipment Parking Address _ •iZ� <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 t <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time . h <br /> 4. 11 SANITATION PERMIT ( ' <br /> Job Address/Location a IZ <br /> Owne ��.L11LLi �I, ��-,.�� Address_ �•'AI • <br /> SEPTIC TANK f IJ CESSPOOL UP-TEACHING FI <br /> " EACHING ELD=© SEEP-AGEPIT 11 PACKAGE PLANT <br /> ❑ PERMANENT .> ❑ TEMPORARY`"' ❑ 'I EW �, r❑ REPAIR 13 OTHER Y <br /> 5. 11 CHEMICAL TOILETS For July 1; -June 30, 19 <br /> Type Construction "Disposal Site <br /> No. of Units Equipment Storage/C14an1 rig,Lbcation(s) Y . <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 /> �-• w. I <br /> SIZE: IJLess Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.= <br /> ❑ DRY CLEAN INGrChemicals Used/Amount/Mo. <br /> w , <br /> herebyccertify 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 regulations of the San Joaquin Local Health District. w <br /> APPLICANT'S SIGNATURE X <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> FFE <br /> Due: C] ANNUALLY K PER UNIT —E] PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING EMITTANCE $ AMOUNT DUE CHECKED <br /> DATE PATE REMITTEDAMOUNT <br /> � t <br /> i j �� X17 <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 1601 E.HAZELTON AVE.,P.O.box 2009 6TOCKTON,CA 95201 <br />