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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> Q - ,.y. (For Non-transferable,Revocatite,rand Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT , <br /> LIQUID WASTE <br /> Applica ' is hereby mad to ca ry+on u iness In the j isdictional area of then oaquui LLoc�al Health District ' I� <br /> y Busines ame (DBA) .� Address.._/� <br /> z Owne �d �• �G�'>�t�-�� Address <br /> a _ . <br /> J Firm Partners, Addresses and Tele hone Numbers <br /> IL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants.Name (Print) o t - Title Date <br /> ,i <br /> x <br /> Please`ch#Ok Applto*'a�ble'C gory(1-7) and Fill the Requfired Information-., <br /> 1. ❑PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, '•- June'30'19 . 7--Disposal Sites <br /> Description(Make/Yr:;Color)'"` <br /> y Serial No T CAL. License No. CAL. License Renewal No. t� <br /> . ' Gal.,Weights 8 Measures Nor`` l i <br /> Capacity' ' <br /> Equiprr?entParki`ng,Address <br /> 2. ❑ PUMPER YARD <br /> For July 1; `�Jline 3019 <br /> No. of Vehicles Stored x <br /> No. of Chemical Toilets Stored <br /> 3. © PERCOLATION TEST 1 <br /> R.S. or R.C. ,Name ) R.S. or R.C.E. No. I <br /> Test Location_ TTest Date/Time ! + <br /> 4. ®SANITATiON PE QZ; y� y f <br /> Job Addr s/L'oc ion� / f <br /> Owner <br /> WSEPTIC TANK ❑ CESSPOOL-- AHING FIELD 11 SEEPAGE PIT 1:1 PACKAGE PLANET <br /> W"PERMA'NEN-T, ,,❑`TEMPORARYj 1 NEW `R t ; 11 REPAIR ❑ OTHER <br /> 5. 13CH,EMICAL TOILETS For July,1, -June 30, 19 ; q <br /> Type Construction f I Disposal Site _- <br /> i t - <br /> No. of Units_ ( '- EQuipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 C <br /> V 1 <br /> Operator Mame `^' _ y a —_ Where Certified __ { <br /> Plant Location <br /> Plant Capacity No. Units Served . 3 <br /> 7. 13 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 /> Home ownercragent's sigrioviecerfflesthe following "Irertifythat1ri.the perforinanb's <br /> cetbeiverkf�rwhl6hthispermitIstSSLted,IshaltnotemPEayanypesson <br /> I"A?:f.I!!Fi iJi:!'C: tCCifr"•Zil'.:,;;Dj$'. ...,, :.2i: Gl'r{lir�c''i t!�.,.-._ "`('u i.�1€''::�t It <br /> !%4ing or•::ub i2.'�Ctir,r ,:[fSY.':IS7 C_r:>:ir_: S.,r?pi:a=v.in 1 i:27i'4t:ia,:ri:tie perforn,,ance tf'he: c,k fnrSh chi 9F permit lit is lssue_1 shalt <br /> Hi.::�,•;;.C:v';.;:...3ilj'.:%i..:d6iSirT1�!�b <br /> hereby certify that I .have prepared this application and that the work will be done'!n4accordance'with San Joaquin County Y <br /> ordinances, state laws, and rules and regu tion f.the' San Joaquin Local Health District. I <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> it f <br /> Fee Is Due: 11ANNUALLY ElPER UNIT 11PER SITE ElEACH 0 January 1 &Received By January 31 © July 1 &Received By July 31t <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> - AMOUNT 's ;11 <br /> FEE <br /> LESS w <br /> PRORATION' ` <br /> PLUS <br /> a g <br /> 'PENALTY' <br /> OTHER . ` <br /> OTHER t <br /> Received by Date , - -;Receipt No. - - Permit No. .. Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2909 STOCKTON,CA 95201 <br /> w <br />