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Applications Will Be Processed When Submllted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT ; <br /> LIQUID WASTE a <br /> Application is h b e to carry busi s in he jurisdictional area of the San Joaquin Local Health .strict,. <br /> N Business Name {BA) T12 4-6 y r Address <br /> _ ) <br /> i Owner P 1G,f< Address 3 <br /> C i <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 1 Emergency Telephone No. . <br /> Contractor Licence No. + <br /> Applicants Name (Print) t Title A . Date <br /> Please check Applicable Category (1-7),and{Fill in the Required Information j <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t <br /> For July 1, June 30,-19= -..Disposal Sites is <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Gal.,Weights &Measures No. _. <br /> Equipment Parking Address i- -- - <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored - <br /> t <br /> No. of Chemical Toilets Stored <br /> :3. ❑ PERCOLATION TEST <br /> � <br /> R.S.or R.C.E.'Name R.S. or R.C.E. No. ;i <br /> S k <br /> c <br /> Test Location Test Date/Time x <br /> 4. WSANITATION PERMIT f 5-0 <br /> Job Address/Locatio G� <br /> r <br /> Owner Voekla Address <br /> Dk� 611EPTIC TANK CESSPOOL �EACHING FIELD 1:1 SEEPAGE PIT 13 PACKAGE PLANT <br /> U4F <br /> ERMANENT ❑ TEMPORARY4NEW. C1 REPAIR 11 OTHER x <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30; 19.E <br /> _ »�'-:,F-. __-Disposal Site <br /> Type Construction <br /> t.+r,rr 3 i <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> t. <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,.-June 30, 19 } <br /> Operator Name - <br /> Where Certifled' j <br /> t � { <br /> Plant Location <br /> Plant Capacity ! No. Units Served # i <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 /> 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 egulati s of the an Joaquin Local Health . <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: 11ANNUALLY - _❑ PER UNIT, ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> - - REMIT <br /> ^ EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE <br /> - DATE - DATE REMITTED AMOUNT <br /> FEEyr <br /> LESS _ <br /> PRORATION / <br /> PLUS — <br /> PENALTY - -. <br /> OTHER , <br /> OTHER .i. <br /> •Receipt•No. Permit No. = Issu nce a Mailed Delivered <br /> Received 6y Date <br /> -- 1601 E.HAZEL N P.O.Bvx 2009 STOGKTON,CA 95201 <br /> APPLICANT=R€TURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES „ <br />