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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 i h reby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name BA) Address ,r`� Cf'7�ta�c� <br /> z Owner Address '2 ©" qtt <br /> a <br /> L) Firm Partners, Addresses and Tel one Numbers <br /> CL Business Telephone No. Emergency Telephone No. <br /> a <br /> ' Contractor Licence No. <br /> Applicants Name (Print) C Title fidC944—,-­ Date <br /> f Please check Applicable Category (1-7)and Fill in the Required Information r� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) x'263 S`o. 5 SEPTIC & S Vd�R SERVICE V <br /> For July 1, June 30, 19 Disposal Sites 2C� efl• "10 �` cn!r tGn. Ca if. 95217 <br /> 4 4'6` <br /> ,.f -�iU� CODifc CSV"'S I!. I.-67177 <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. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERM <br /> Job Address/Location -3-3 .p r <br /> r Owner Address <br /> VSEPTIC TANK ❑ CESSPOOL LEACHING FIELD k T ❑ PACKAGE PLANT <br /> VPERMANENT ❑ TEMPORARY >YNEW ❑ REPAIR�4-4V❑ OTHER w <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 GV <br /> I Type Construction Disposal Site l� <br /> 4 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r <br /> k Operator Name Where Certified 7� <br /> r Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> r SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> F ❑ 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 regulations of the San Jo quin LV Health District. <br /> '�nAPPLICANT'S SIGNATURE X - [C SERVIGE <br /> 2663 :o. V;O Y/ .510v�, n, L•is'!if. 9.206' <br /> +'-lF ry II Jl}Ir � <br /> � P�•=a�J-. 209 r 2�,C;S I_IC. 1"ii/17 <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 /> - REMIT <br /> BASE EXPLANATION, BILLING REMITTANCE $ AMOUNT DUE CHECKED - <br /> (� f( DATE DATE REMITTED AMOUNT <br /> EEE -l l` <br /> LESS <br /> PRORATION <br /> f PLUS <br /> PENALTY i <br /> I OTHER <br /> i OTHER <br /> f' <br /> r Received by Date Receipt No. Permit No. Issuanceate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTONAVE.,P.O.Box 2009 STOCKTON,CA 95201 V <br /> b: <br />