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- TApplications Will Be Processed When%ubmittW Properly Completed, Be Sure To Sign The Application. <br /> v APPLICATION r <br /> i, (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> - LIQUID WASTE <br /> Application is hereby made to carry on business in jurisdictional area of the San Joaquin Local Health District <br /> G Address <br /> tiBusiness Name (DBA) P A- <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> 0 Business Telephone No. �— `� Emergency Telephone No. <br /> a Zy '--3t1,3 <br /> �Contractor Licence No. �-�-j �g. Q 12- Date — z � <br /> �T�rxIL _ y1 S Title C� <br /> �Applicants Name (Print) . <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) CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> } <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 w <br /> No. of Veriiicles Stored <br /> No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST R.S. or R.C.E. No. i <br /> R.S. or R.C.E. Name <br /> Test�Loc tion Test Date/Time <br /> 4. I t SANITATION PERMIT <br /> Job Address/Location 7-5 �Z AQI�� Address <br /> f Owner (P/J F Addres,�s� <br /> ❑ SEPTIC TANK ❑ CESSPOOL EILEACHING FIELD L'� SEEPAGE PIT 13 PACKAGE PLANT <br /> 21ERMANENT 13 TEMPORARY ❑ NEW IS REPAIR 11 OTHER 1 , <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site f v <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> _ 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified - <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 /> k � <br /> ' I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d rules and regulations f the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> u <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRd By July 31 <br /> IT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> f <br /> OTHER <br /> r <br /> OTHER <br /> � � <br /> Received by <br /> Date Receipt No. Permit No. - _ ssuan a Date Mailed Delivered <br /> _ <br /> 009 STOCKTON,CA 95207 <br /> APPLICAi�1T---„{iETUR ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2 <br />