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@y,pplicollons Will Be'Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE I E <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> - Application is hereby made to carryon bus'_ ss in t e' risdictianal area of the San Joaquinocal Health DistucL <br /> y Business Name (DBA) Address� S , <br /> z Owner L- L Address — <br /> a <br /> 3 Firm Partners, Addresses a d Telephone�1u bers <br /> i a Business Telephone No. Emergency Telephone No. <br /> -j Contractor Licence No. ..T <br /> � <br /> Applicants Name (Print) Title ate <br /> Please check Applicable Category(1-7)and Fill in the Required Information C16 <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites r 1 <br /> Description(Make/Yr., Color) UJ <br /> Serial No. CAL. License No.. " CAL. Liccnse Rencwal No. <br /> r- __4 _ .... - <br /> -Capacity Gal., Weights &-Measures NU.—. "*""'" � '" <br /> Equipment Parking Address <br /> 2, ❑ PUMPER YARD <br /> For July 1, June 30, 19 — <br /> No. <br /> 9 No. of Vehicles Stored--- <br /> No.'of <br /> tored _No'of Chemical Toilets Stored <br /> 3. "❑ PERCOLATION TEST - - <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> t Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT t <br /> Job Address/Location w <br /> Owner Address <br /> F <br /> El -SEPTIC TANK E] CESSPOOL LEACHING FIELD �SEEPAGEPIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY E-1NEW REPAIR ❑ OTHER <br /> 13 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> 1 � <br /> Type Construction --Disposal Site <br /> No:of Units Equipment Storage/Cleaning Locatibn(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June.30, 19 W <br /> I Where Certified <br /> Operator Name <br /> } Plant Location �- - <br /> Plant Capacity No. Units Served <br /> '7: ❑ LAUNDRY For July 1, -June 30, 19— <br /> SIZE: <br /> 9 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq, Ft. <br /> 13 'DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby=certify t a ave prepar d this appli tion and that the work will be done in accordance with San Joaquin County <br /> ordinances, stat laws,a r le an r the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> AVQ Q <br /> FOR DEPARTMENT USE ONLY <br /> " 6 <br /> Fee Is Due: El ANNUALLY El PER UNIT ❑ PER SITE EACH ❑ January 1"&Received By January 31 ❑ July 1 &Received By Jury 31 <br /> F � i REMIT <br /> i -RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 7 <br /> -a DATE DATE REMI TED AMOUNT <br /> FEE FII L4LESS ; <br /> .. is <br /> PRORATION <br /> -fold <br /> PLUS 'T+ �1 .� YJ,dt I'1PnJ ryvJr .# <br /> ( PENALTY' ca 5 4) /t lot <br /> OTHER Yev.std �r�r..n �y S�/jId'1 - YJ+�n. rav�o vrk''� r y <br /> �e OTHER <br /> Received b Date Receipt No. Permit No. Is uan �,� M,,.d pelivered j <br /> i e <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES t 16Q1 E.HAZELTON AVE.,P.O.Box 2009 .STOGKTON,CA 95201 <br />