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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION i <br /> -(For Non-TransferableRevocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTHiP.ERMIT <br /> LIQUID WASTE - <br /> Application is h reburdie4ortr usiness in the jurisdictional area of-the San Joaquin Local Health District <br /> OFBusiness Name (DBA) � Address,. M <br /> z Owner , C Address - <br /> Firm Partners,Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. Emergency Telephone No.- - <br /> _J Contractor,Licence No. _ - <br /> L Applicants Name (Print) ilYl r JI! 1 . -f ��f�f� �. _ -Title Date { <br /> Please check Applicable Category (1-7) and Fill in the Required Information - i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> For'July 1, - -_June 30, 19= = Disposall 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 StoredI -f_ <br /> 3. 11 PERCOLATION TEST kms-- � `' <br /> R.S. or.R.C.E. Name t R.S. or,R.C.E. No. <br /> Test•Loct Ion t � ( � � - r TestDate/Time - <br /> ` <br /> 4. -:;.SANITATION PERMIT-. . <br /> JobsAddress/Location bwf E l f <br /> Owner t tl e� h uY Addr ' ' — a <br /> ❑ SEPTIC TANK C1CESSPOOL, 0 LEACHING FIELD f. ❑ S EPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORAR.Y ❑ NEWFIEPAIR 11 OTHER fti <br /> 5. ❑ CHEMICAL TOILETS For JulyA,;,,June,30_1 r Sl. <br /> Type Construction - Disposal Site;: I <br /> No. of Units ' Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For Julytl', -June 30,.1$, <br /> Operator.Name Where Certified <br /> Plant Location —� <br /> Plant'Capacity No. Units Served <br /> 7. ❑, LAUNDRY For July 1, -June 30, 19 t F <br /> SIZE: 0 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - t <br /> t" 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. <br /> APPLICANT'S SIGNATURE X `� r <br /> '• + FOR DEPARTMENT USE ONLY I <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE 11 EACH. 0 January 1 &Received By January 31 ❑ July 1 &Received By July'31 <br /> REMIT <br /> 3 1 BILLING REMITTANCE^ $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE —REMITTED - 'AMOUNT <br /> - <br /> . <br /> LESS_ <br /> i <br /> PRORATION - <br /> �, <br /> PLUS � �- :n!�`I �-. • <br /> tr PENALTY <br /> OTHER <br /> OTHER .}. <br /> r <br /> 3 33 . L <br /> Received by - Date a Receipt No Permit No. Iss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: <br /> -y ENVIRONMENTAL'HEALTH PERMIT/SERVICES- 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br /> CD yk.ti 4 <br />