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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 ereby made t arty on b 'ness i the juris 'ctional area of the Sap-)o qui Loc��alb District <br /> IT Business Name (DBA) Address ! <br /> i Owner Address - <br /> a <br /> Firm Partners, Addresses and Telephone N tubers - tom. <br /> aBusiness Telephone No. �� "�`S' ' Emergency Telephone No. z <br /> Contractor.Licence No. a-fi <br /> LApplicants Name (Print) Title . Date <br /> yy.s _. i ' <br /> Please check Applicable Category (1-7) and Fill in the Require "Information <br /> 1*I.OFP.UMPER 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 �' -f i Gal.,Weights & Measures No. <br /> Equipment ParkingAddress <br /> 2. 13PUMPER�YARD . <br /> For July 1., June3d,.19�' <br /> No."of Uetiidles Stored <br /> .No. of Chem ic`al,ToilletsStored <br /> 3. ©PERCOLATION'TEST <br /> R.S.-or R.C.E.,Name - R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4, ❑ SANITATION PERMIT <br /> Job Address/L catio !�� r <br /> Owner &11, )i AddreMS31E. <br /> 11 SEPTIC TANK 11 CESSPOOL ❑ LEACHING FIELD AGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW EPAIR ❑ OTHER q( <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �4 I <br /> Type Construction J Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 5. 11PACKAGE TREATMENT PLANT ForiJuly 1, -June 30, 19 <br /> Operator Name l] Where Certified <br /> Plant Location <br /> Plant Capacity ) _y'' No. Units S rved <br /> 7. 11 LAUNDRY For July 1, -June 30, 1`9f (a <br /> SIZE: ❑.Less Than 1,000 Sq. Ft�, ❑ More Than 1,000 Sq. Ft. t111, +#; <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. " <br /> AIL 4 <br /> I hereby certify that I have prepared this application and that the.work-wilt be done in acc d' Le w thVJoaquin County <br /> ordinances, state laws, and rules nb regulations of th San'Joaquin_Local Health District. <br /> APPLICANT'S SIGNATURE X `t <br /> k FOR DEPARTLREMITTAN <br /> USE ONLY <br /> i r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EAC ❑ J nary l Received By January 31 r 0_JUIyArB Received By July 31 �. <br /> f }$ REMIT <br /> BILLING 1 AMOUNTDUE CHECKED <br /> BASE EXPLANATION 'DATE TE REMITTED AMOUNT <br /> FEE j <br /> LESS <br /> PRORATION <br /> PLUS I <br /> PENALTY r <br /> OTHER <br /> OTHER <br /> -Received by Date Receipt No Permit No. Issuance Date Mailed Delivered I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box'21309 -STOCKTON,CA 95201 <br /> fiY <br />