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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION _ <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGi <br /> ' LIQUID WASTE (A s-1 p_g),' <br /> Application is ereby made to <br /> carry on business in the jurisdictional area of the San Joaquin Local Health District. <br /> f y Business Name(DBA) z <br /> Address <br /> a Owner Address <br /> j Firm Partners, Addresses and Telephone Numbers <br /> cBusiness Telephone No. — ' J. Emergency Telephone No. <br /> i _J Contractor Licence No. <br /> 4 <br /> L Applicants Name (Print) /'• LL.L� - Title <br /> Please check APPCategory,licable (1-7)and Fill in the Required Information Date ' <br /> � --' <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. CAL. License Renewal No. <br /> Capacity, i Gal., Weights & Measures No. . <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 4 <br /> For July 1, June 30, 19 r 'z <br /> No. of Vehicles Stored <br /> .No. of Chemical Toilets Sibred I <br /> 3. ❑ PERCOLATION TEST I t t <br /> R.S. or R:C.E. Name R.S.or R.C.E. Na <br /> Test Location '� <br /> Test Date/Time <br /> . r h � <br /> 4. 13 SANITATION PERMIT = <br /> Job Address/Location <br /> Owner <br /> Address <br /> -159 SEPTIC TANK ❑ CESSPOOL �.LEACHING,FfELD ❑' G <br /> S�1 PAGE_PIT ❑-PAGKAGE_eLAIVT <br /> ❑ PERMANENT ❑ TEMPORARY ❑'NEW ❑ REPAIR ❑ OTHt R r <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction w, }t Disposal Site <br /> v� <br /> No. of Ul itsI <br /> 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 /> �meownerartirnn�A#r-r s s � -4� x` _ # ? <br /> lit Such manner a5-@ b L� 81 r 7 .r r A- h �^�r^+iA 3 .,! Grrfyl �• f .:- <br /> e ta. �theaerformanceo#tfiewoktnrt�#rlchthisperrn;tisis;�eJ <br /> Coiltracter'3 tllrirl S F _ 7155$1t,d'ia:nrl etGm�lOy&rljfit:rS?; � <br /> employ D �; s- E-.Jir� r <br /> p oy parsons suC;ac:,a tale at:rrr9; '1 cei;;r, !bat in Oc perionr;ance O,t11e:vcrk fL'f <br /> a5io of Cal, rlia." j N9r ?ii i5 ISS'.�"�,i;ihail <br /> I hereby certify that I have prepared this application a r)d_that_the.work wjll_be dQoe-in accorda_n_c_e with San Joaquin County <br /> r ordinances, state laws, and rules and reg tions f the Sar?Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X { <br /> p.. <br /> �f •'r <br /> FOR DEPARTMENT USE ONLY # <br /> Fee IS DUB: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE . ❑ EACH ❑ January 1 &Received By'January 31 ❑ July 1 &Received By Juty 31 <br /> { <br /> 4 BASE EXPLANATION BILLING REMITTANCE $ ' REMIT <br /> DATE DATE - 'REMITTED _ 'AMOUNT DUE CHECKED <br /> FEE `+rP AMOUNT j <br /> LESS <br /> PRORATION �(r V el e GY <br /> PLUS 0 <br /> PENALTY Q V d)f i; .ISI✓ 3 �� f y <br /> OTHER <br /> t ) r <br /> OTHER <br /> n <br /> Received byDate Receipt No. a . Permit No <br /> ssua a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br /> ,� 1601 E.HAZELTON AVE„P.O.Box 2009 STOCKTON,CA 95201 ' <br />