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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 'r <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 /> FBusiness Name (DBA) Address + :V- S72�Ic/ <br /> % Owner Address <br /> J Firm Partners, Addresses and Telephone Numb. rs <br /> 0.a Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) ►' 3Ds_„iF Title Date µ _ <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) <br /> Serial No. CAL. License No. f.:, CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. � <br /> _— <br /> Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored 1 <br /> No. of Chemical Toilets Stored ' <br /> 3. ❑ PERCOLATION TEST s <br /> R.S. or R.C.E. Name t�-- _.. F`� ' R.S. or R.C.E. No. <br /> Test Location t t� <br /> - Test Date/Time <br /> 4. A SANITATION PERMIT ! _ <br /> Job Address/Location,- <br /> Owner _ �F� 1 L" G, �j _ — Address ► "Z: _ <br /> ❑ SEPTIC TANK ❑`CESSPOOL"'• ❑'LEACHING FIELD C1 SEEPAGE PIT t ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY, .-❑ NEW 4 REPAIR OTHER ' <br /> 5. 1:1CHEMICACTOICETS,..F.or July-1;-June•30, 19 :� <br /> , .r N <br /> Type Construction�t �Q Disposal" ire <br /> No. of Units rr w Equipment Storage7Gleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT—For&Iy 1; -June_s3 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 /> • 1 <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 regallatiioi6ns of thlle�Slan• I� <br /> Joaquin Local alth District. <br /> APPLICANT'S SIGNATUREX '`"' <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 /> EASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> � AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> r <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 PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 . <br />