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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION "`"` ry <br /> (For Non-Transieiabie, Revocable,`and Suspendable) SEPTAGE <br /> '— ENVIRONMENTAL HEALTH PERMIT <br /> (�2 Z "E"ZVI LIQUID WASTE <br /> Application is ereby made to car on business in the jurisdictional area of the San Joaquin Local Health District <br /> In Business Name (DBA) 14L w . _ Address <br /> aOwner �L Address <br /> I J Firm Partners, Addresses and Telephone Numbers _ <br /> CL <br /> Business Telephone No. L Emergency Telephone No: <br /> -J Contractor Licence No. <br /> cz <br /> L Applicants Name (Print) /� L �ULL� 'Title; C[J � 1 Date Imo, �' <br /> Please check Applicable Category (1-7)and Fill in the Required Information - <br /> I 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> l For July 1, June 30, 19 Disposal Sites - <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. i CAL. License Renewal No. <br /> Capacity - Gal.,lWeights &Measures <br /> Equipment:•Parking Address c '` <br /> 2._❑ PUMPER YARD ! t s <br /> For JTly-1, June 30, 19 <br /> No. of Vehicles Stored I <br /> -11�No. of Chemical Toilets Stored <br /> C' <br /> 3. ❑ PERCOLATION TEST .� <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. -� <br /> t Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT tv ` F <br /> Jab Address/Location <br /> 1 Owner z A.4 Address % 3 <br /> SEPTIC TANK 13 CESSPOOL 11 LEACHING FIELD 1:1 SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW @REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS Fbr July 1, -June 30, 19 <br /> I <br /> Type Construction Disposal Site <br /> No. of Units ' Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July;1, -June 30, 19 <br /> Operator.Name <br /> Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served # <br /> 7. ❑ LAUNDRY For July 1,, -June 30;-19 ^'� <br /> SIZE: ❑ Less'F•han 1;000 Sq. Ft., � ❑#More Than 1 000 Sq.-Ft. [ i <br /> ❑ DRY CLEANING, Chemicals UsedJA o nt/Mo. <br /> r i : <br /> ,� <br /> t I hereby,certify that I have prepared this application and that the work will be done in accordance with San quin County <br /> I€ 1 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> r + <br /> APPLICANT'S.SIGNATURE.X_ �z� <br /> I, FOR DEPARTMENT USE ONLY fF <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31., ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED' <br /> - DATE DATE - REMITTED .. AMOUNT <br /> r'. <br /> FEE <br /> LESS F. , <br /> PRORATION ` - <br /> PLUS I <br /> PENALTY I <br /> OTHER E.n ° w .�• _�� :a�! - <br /> I <br /> - - <br /> Received by Date Receipt.Na. Permit No. Iss once ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES',,„ 1901 E.HAZELTON AVE.,P.O.Bac 2009 STOCKTON,CA 95201 _ <br />