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...�_ ,.. <br /> Applications Will Be Processed When Sub�PPLiCAT�ONroperly p e e . <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT �! <br /> LIQUID WASTE ` <br /> Application is hereby.made to ca on b siinness in the jurisdictional area of the San Joaquin Locate ealth.District <br /> Address ' <br /> —1 <br /> `Business Name (DBA) Address <br /> z Owner C <br /> 9 _ p <br /> j Firm Partners, Addresses and Telephone Numbers' Emergency Telephone No. W <br /> CL Business Telephone No. f �� <br /> _JContractor Licence No. y Title —;� Date <br /> L Applicants Name(Print) <br /> -7) and Fill in the Required Information <br /> Please check Applicable Category (1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19' - Disposal Sites <br /> Description(Make/Yr., Color) CAL. License No. CAL. License Renewal No. <br /> Serial No. l <br /> Capacity <br /> Gal.,Weights& Measures No. 1 <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30. 19 4 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored } <br /> 3, ❑ PERCOLATION TEST R.S.or R.C.E. No. <br /> R.S. or R.C.E.Name I Test Date/Time <br /> Test Location .�"� / <br /> a, ANITATION PERMIT ` .¢d �i WAI <br /> I <br /> Job Address/Location Address10 <br /> Owner l/ ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK CESSPOOL LEACHING FIELD 'SEEPAGE PIT OTHER <br /> 13 PERMANENT ❑ TEMPORARY ❑ NEW L-EI REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19 <br /> Type Construction <br /> Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> .g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 11 More Than ],004 Sq.`Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> / AZI <br /> < 14� - <br /> I hereby certify that I have prepared this application and that the work will be done iri accordance with San Joaquin County <br /> Joaquin Local Health District. <br /> ordinances, state laws, and r s and re lations fAhe San / <br /> APPLICANT'S SIGNATURE X e <br /> . � 2 <br /> FOR DEPARTMENT USE ONLY <br /> ❑ EACH C1 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee is Due: C3 ANNUALLY ❑ PER UNIT ❑ PER SITE REMIT <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE "C <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER i <br /> - - t�' � � �l suan e Dat Mailed 4elivered <br /> Hate :Receipt No. Permit No. <br /> Received 6y � - - 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />