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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Translerable, Revocable,and Suspendable) SEPTAGE <br /> ` ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) Address <br /> z Owner Address 2 J7 #4441i <br /> a <br /> 9 Firm Partners, Addresses and Telephone Numbers <br /> 'a Business Telephone No. Emergency Telephone No. ; <br /> a <br /> Contractor Licence No. <br /> Applicants Name (Pring Title Date40 <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 34, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> (4.kSSANITATION PERMITob Address/ anonwn Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD &'SEEPAGEPIT PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> ype Construction Disposal Site Pf7 <br /> o. of Units Equipment Storage/Cleaning Location(s) <br /> ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served ' <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 /> n ^y any parza <br /> Name oln:rtaPorlice:nsad agr..f11's>;ir�ti�hlr�a^''-''�"sti;r�#iltlalt?Aq' 'I C2{tl�f�?hPt in the perterrtanceat s9e'rrork or which this permitJSissuecl.I shall not e..,..� <br /> i:. scf vafii r:Iia' tail <br /> irl s sc':rr.ulre a .o necol ;stl_t;ea it; ;ers lio i in "I cerin} that ill the perfornianc f the,:rn k.frttv`$ <br /> or <br /> suh-Crn+rB^Ei,. `ec t`ic taI'Dw g: <br /> Gon::a�tv'S it.riry Otrt GnSc.',�, ,u::sCJIjlw'niz <br /> en=p:ay 'l rsans a�Gject tv�.orkmas!'s c <br /> I hereby certify that 'd prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state la s, nd rules and reg ions of the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> f 4L SCt1 L 34-92 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 13 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> SASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> yt �Ob <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS -� <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received By Dile I Receipt No, Permit No. Issuance Dat Mailed Delivered <br /> C APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sol 2009 -STOCKTON,CA 95201 <br />