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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. ? <br /> jAPPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE i <br /> I LIQUID WASTE <br /> Applica ' n is<h reby ade t carryon bu in sn t jurisdictionak area of th Jaaqu' Local Health District , <br />,,Busines ame (DBA Address <br /> I- Owne Address. <br /> C <br /> Firm Partners. Addresses and Tel pho a Numbers <br /> a Business Telephone No. Emergency Telephone No. - # <br /> 4 / _ I <br /> � Contractor Licence No. 4,G7 All <br /> LApplicants Name (Print) Title Date 4 <br />^Please check.Applicable, gory (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER:VEHICLE-_PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1' �Ll6h 30, 19 Disposal Sites # - <br /> Descrlption ake/Yr. Coiot)° _ <br /> r (M 3 � <br /> Serial No'*'� CAL. License No. CAL. License Renewal No. <br /> Capac 1 y = "'' ` '" - Gal., Weights& Measures'No. <br /> Equipment Parking Address_ <br /> • *- � <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 Id } <br /> No. of Vehicles Stored <br /> .No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R,C.E. Name I R.S'or R.C.E. No. _ <br /> Test tion " Test Date/Time- r <br /> 4. I�SANITATION PE IT I� "`" �"` 14 <br /> Job Addr s ocation <br /> Owner Address . .. ; <br /> ❑ SEPTIC TAN 1:1 CESSPOOL R'CEACHING-FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> Ods'# <br /> ❑ PERMANENT ❑ TEMPORARY El NEW � EPAIR <br /> 5. 1:1 CHEMICAL TOILETS For July 1, -June 30, 19 •k-L tel,;y <br /> Type Construction Disposaltite <br /> No. of Units Equipment Storage/(Leaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30",19Y s ] <br /> h1 Where Certified i <br /> Operator Name {� <br /> Plant Location ' <br /> Plant Capacity ;: •; No: Units 5erve <br /> El - <br /> d ; <br /> 7. LAUNDRY For July 1, June 30, 19t; € "`;+ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. .�. ' t <br /> o,�se+h�cForfr dA prC ac,o c t 1 <br /> 1;35:iCil',}�ln_f c - SS tururc _c^+' F t a�i:rY� ',1$ ILEi�hl t,ti rItrf�w�vr'"19r:Cc6i��C�!✓ s ;^ r i 1 <br /> Rrl! Gi ,I�rltili5�.�,rf711t1i155110d,i5hZllr?Dtenl lc e <br /> Gan'r�ctnr's .r,. �, ti P yunyp rson <br /> ,% i.,.ii7G.? <br /> for k°Jh,C,.1.. "i'"!I{ 15f dII <br /> w <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 ules and regu ion of'the San Joaquin Local Health District. 4 t <br /> APPLICANT'S SIGNATURE X <br /> i <br /> I� F <br /> FOR DEPARTMENT USE ONLY <br /> iS <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT ❑ PER SITE'[ <br /> ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> + REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE •CHECKED <br /> E!�DATE DATE REMITTED t AMOUNT <br /> FEE LESS <br /> PRORAT30N .la - <br /> y <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER s - �ih' - ✓/ <br /> OTHER + <br /> i y <br /> Received by Dale Receipt No.- Permit No. msuancd_Date Mailed Delivered I <br /> - APPLICANT—RETURN ALL COPIES TO: .�ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1801.E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 " <br />