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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 is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) '" NTW6AJV Address -p('0 C�� �/✓�. /1�LPr�� - <br /> aOwner -., — Address <br /> Firm Partners, Addresses and Telephone Num ers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> d Contractor Licence No. �. <br /> L Applicants Name (Print) y ..Title Date <br /> Please check Applicable Category (1-7)-and FillInthe 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) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored -t <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION:TEST z "' <br /> R.S. or R.C.E. Name ' " .. R.S. or R.C.E. No. , <br /> Test Lo tion Test Date/Tim,j <br /> 4. liff SANITATION PERMIT (I i <br /> Job Address/Location c�. ./ln �J f� &ljceA <br /> Owr}er , , Address�- Z <br /> SEPTIC TANK C1 'CESSPOOL LEACHING FIELD''_O SEEPAGrE PIT ❑ PACKAGE PLANT ! ` <br /> ❑ PERMANENT ❑ TEMPORARY 11NEW ❑'REPAIRt ❑ OTHER } <br /> 5. ❑ CHEMICAL TOILETS For-,July 1, -June 30, 19 j s <br /> Type Constructionr Disposal Site 1 <br /> No. of Units #+ Equipment Storage/Cleaning Locations) —� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 - I. <br /> Operator Name %` }, 1 Wlfere Certified <br /> Plant Location / # � <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, `June-30,"1s _ .? s <br /> 'SIZE: ❑ Less Than 1,000 Sq. Ft, ❑ More Than-,1,000 5q. Fl. j rJI <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> • - -,-- - ., �'r, <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 r gulati ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> t. <br /> I'? ven <br /> FOR DEPARTMENT USE ONLY .A <br /> #:rbc <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE �❑ EACH ❑ January t &Received By•January 31 July t &Received By July 31 <br /> BILLING REMITTANCE $ t _ REMIT <br /> BASE EXPLANATION /� AMOUNT DUE CHECKED ' <br /> ,�,. -T; _DA +.� DATE »,:REMITTED. ..-.- -. _ <br /> t AMOUNT <br /> a; <br /> FEE-- - G1t ° -x•--• _, ..' - .� ., -.� <br /> LESS 'O ,alt• f ' <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER } <br /> f• is r, ' `..r"" <br /> Received,by „- Date Receipt No. Permit No Issuance D to Mailed {Delivered <br /> APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201 } <br />