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a Applicatiolis Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r' <br /> APPLICATION <br /> A Y (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 646x", e <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District e <br /> Q Business Name (DBA) �'�'eleZeAq- C -TAMC, Address 4/'i . 1Yd?e ,oq,ej�•-0?' f2e <br /> z Owner Lam. ✓'C'h'c� �-i. /[ Address ®G i�'�. Tf t/�L-+ C �'•� 9S !� <br /> a. <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ' Emergency Telephone No. <br /> Contractor Licence No. 1 _ <br /> L Applicants!Name (Print) ���'��� ��• � Title —�Q�®p Date �l07 <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites. <br /> Description(Make/Yr., Color) t <br /> Serial No. CAL. License No, CAL. License Renewal No. <br /> Capacity - Gal., Weights & Measures No, - `I <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored e <br /> No. of Chemical Toilets Stored <br /> ;S <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 r� <br /> 4. W SANITATION PERMIT I �' <br /> Job Address/Location <br /> Owner Address <br /> �S SEPTIC TANK ❑ CESSPOOL LEACHING.FIELD ❑.SEEPAGE PIT_D.PACKAGE PLAN_ T _ I <br /> I PERMANENT ❑ TEMPORARY pu NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r <br /> Type Construction i Disposal Site I <br /> No. of Units Equipment Storage/Cleaning Location(s) ti <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certifiedh. <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> is <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 rLIOs and egulations of the San Joaquin Local Health District. p <br /> APPLICANT'S SIGNATURE _. <br /> pr FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ql PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 11 DATE DATE REMITTED _ AMOUNT <br /> � I <br /> FEE Lf S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> a. B <br /> � 1p <br /> 7 <br /> ea4aolrt <br /> Received by Date Receipt No. Pprmit No. - - lssuan a Dalb Mailed Deliver d i <br /> APPLICANT-RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 - <br /> _ <br />