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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 Joaquin Local Health District <br /> yBusiness Name (DBA) Address <br /> a Owner :TEPPY In_IP_kN Address RRIr-sT' R06t:l FF_E'tvC44 CAA <br /> J Firm Partners, Addresses and Telephone Numbers <br /> K Telephone No. (LC�q 9 g3 — 1 6 ?- Emergency Telephone No. <br /> a <br /> Contractor Licence No. c� # ii�AQ <br /> Applicants Name (Print) yVAi,-1'E12 E . C_', .T1'> __ Title Date 4-- <br /> Please check Applicable Category (1-7)and Fill in the Required Information 1 (�/ATTN� til-F�ZA <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) LoLI t,CA 91fn,240 <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. of Chemical Toilets Stored <br /> 3. �3.PERCOLATION TEST <br /> L� zr R.C.E. Name 1' ; _.'Ek <br /> F;,5— R.C.E. No. r'E# 115 <br /> Test Location hd5—t`�R 4-Ek 3 FRIF'-71 F-D. Test Date/Time ,btG ROL cam.- 4-ZP.,- <br /> 4. ❑ SANITATION PERMIT ;2-RSN,71H tz AMS{= CA 11°3-nAm <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 Ole <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 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. f) <br /> APPLICANT'S SIGNATURE X <br /> 1 L\ <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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS I �/ <br /> PRORATION <br /> PLUS t <br /> PENALTY <br /> OTHER <br /> OTHER <br /> R ed by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> A LICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />