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Application`s Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ' APPLICATION j ? <br /> r! (For Non-Transferable, Revocable, and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 9 <br /> LIQUID WASTE I <br /> Applicatio hereby mad tocar on bu i ess in the jurisdictional area of the San Joaquin Local Hemel District <br /> Business Name (DBA), 44M.�l -e /.St, Address Ate. e <br /> aOwner Address <br /> Firm Partners, Addresses and T lephone Number v0 <br /> a Business Telephone No. 3 � Emergency Telephone No. <br /> J Contractor Licence No, <br /> LApplicants Name (Print) 1 Title -0 Date fad�r3� f <br /> Please check Applicable Category (1-7) and IFill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) [� <br /> For July 1, June 30, 19 f� Disposal Sites € <br /> Description(Make/Yr., Color) t l <br /> Serial No. I 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 <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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT [ 1 <br /> Job Address//L cationT� / i�g6A2�o•¢ �" <br /> OwnerAddress 'wc } <br /> @<EE-PTIC TANK• 11CESSPOOL ❑ LEACHING FIELD'1.❑ SEEPAGE PIT El PACKAGE PLANT <br /> © PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June-30,1.9 'k <br /> Type Construction }posal Sites• <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 191 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1- rl-7 1. Cav1 vo.4- re�vvl e'i� <br /> {s CLei/c 1724.1' a <br /> I hereby certify that I have prep d this application arid`that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r nd regulations of Joaggjn cal�lth District. <br /> I <br /> APPLICANT'S SIGNATU K-/ <br /> S <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due. ❑ ANNUALLY- ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Ju#y 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> F <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS .. - - <br /> PENALTY ' <br /> OTHER <br /> OTHER <br /> '79 <br /> Received by - Date Receipt No. Pefmit No. Is uance ate Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ' <br /> r . <br />