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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> A - (77or Non Transferable, Revocable,and Suspendable) SEPTAGE <br /> -ENVIRONMENTAL. HEALTH PERMIT <br /> E LIQUID WASTE <br /> 1 <br /> Application is hereby mad to'carry on business in the jurisdictional area of the San`J�oags�Local District <br /> al <br /> S' Address <br /> rn Business Name (DBA) <br /> aOwner� P —`. 4 � � Address <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No- <br /> d. Business Telephone No. <br /> -------------- <br /> Contractor Licence No.. Title We <br /> Applicants Name {Print}��� L r -, `;` :' <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. <br /> PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Pk, :, ,5. :7 Col,ITYz: 1i 2F�717_l1 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. Licc.-, h'se Rene' ai No. �! <br /> Serial No. CAL. License No. V <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 R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. SANITATION PER ` Q <br /> Job Address/L cation V) <br /> Owner Address <br /> SEPTIC TANK CESSPOOL LEACHING FIELD - ❑ SEEPAGE PIT ❑ PACKA E PLANT``S� < <br /> PERMANENT ❑ TEMPORARY NEIN <br /> ❑ REPAIR OTHER �C17d� <br /> k 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units <br /> Equipment Storage/Cleaning Locatiorl <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,- June 30, 19 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 /> j 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 regulations of the San Joa uin Local Health District. <br /> �I -•n - -;ars; rR ICE <br /> i APPLICANT'S SIGNATURE QrJ %f r ''Ett� {.a;i{. 95205 <br /> I FOR DEPARTME E ONLY <br /> ❑ ❑ PER SITE ❑ FA El January 1 &Received By January 31 E] July 1 &ReceivedREMIT 31 <br /> Fee IS Due: ❑ ANNUALLY PER UNIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> I a <br /> LESS <br /> PRORATION <br /> + PLUS <br /> PENALTY <br /> x <br /> OTHER <br /> OTHER <br /> Received by Da <br /> Receipt No. - Permit No. I suance Date Mailed Delivered <br /> - L HEALTH.PERMIT/SERVICES <br /> 1601 E.NAZELTON AVE.,P.U.Box 2069 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTA <br />