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Applications Will{Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> � i APPLICATION <br /> j (For Non-Translerable, Revocable;and Suspendable) SEPTAGE <br /> �� 3'p ENVIRONMENTAL HEALTH PERMIT. <br /> 0 l� LIQUID WASTE <br /> Appl ication is hereb made to c busi in the jurisdictional area of the San Joaquoc I H Ith D' tric <br /> ' rBusiness Name ( B Address <br /> 10 <br /> a Owner Address ¢ <br /> r �►�� / <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. o � <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information �/}v <br /> 1. ❑ PUMP_ER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J Al <br /> For July 1, June 30,19 Disposal Sites V- <br /> Description(Make/Yr., Color) - <br /> Serial No. ( CAL. License No. CAL. License Renewal No. <br /> Capacity Gal:, Weights &Measures No. <br /> 11 <br /> Equipment Parking Address <br /> r 2. ❑ PUMPER YARD }. Q <br /> For July 1, June 30, 19 f <br /> No. of Vehicles Stored f ' <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST Y <br /> R.S. or R.C.E. Name W-'e f -R.S._or,R.C.E. No.. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT - <br /> Job Addres Loca ion - <br /> /f3 <br /> Owner Address <br /> g SEPTIC TANK El CESSPOOL 11 LEACH ING:FIELD"-­1 SEEPAGE'PIT ❑ PACKAGE PLANT - <br /> ❑ PERMANENT ❑ TEMPORARY O;NEW.. 1 ❑'REPAIR—"' ,—1:1 OTHER \ <br /> 5. ❑ CHEMICAL TOILETS �or July��1,/J--June 30 199�•^ A_ <br /> } Type Construction 2 r (�� ridposal Site <br /> No. of Units Equip"meht-Storage/Cleaning !`6cation(s)• t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name- Where Certified <br /> Plant Location # <br /> ° <br /> Plant Capacity No, Units Served - - <br /> �' - <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ LesstThan 1,000 Sq.-Et.,,, Q.,More,Than 1,,000 Sq. Ft. <br /> F ❑ DRY CLEANING, Chemicals Used/Amount/Mo:-' <br /> fi <br /> 1• q � s'4 <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. <br /> � APPLICANT'S SIGNATURE X . <br /> r ' <br /> { <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11ANNUALLY' ElPER UNIT ❑ PER SITE EACH ❑ January i &Received By January 31 El July 1 8 Received By July 31 <br /> - - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> +' DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PWS ry�7 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r <br /> Received by Date .1 Receipt No. Permit No. Issuance Date. - Mailed Delivered . <br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ' 1601 E:NAZELT 7AN/9ox 2009 - STOCKTON,CA 95201 <br />