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R Applications Will Be-Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> APPLICATION ' <br /> »2' Z`_ji—(For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> y.. LIQUID WASTE z <br /> Appl!cation is hereby made to carry on busines in the jurisdictional area of the San Joaquin L cal Hem District <br /> OBusiness Name (DBA) -� Address ` <br /> a Owner <br /> Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> ILP �a7 Emergency Telephone No. <br /> E Business Telephone No.. ti <br /> �Contractor Licence No. . �: <br /> a Title — ��� - Date i <br /> LApplicants Name (Print) _ -" <br /> Please check Applicable Category (1-7) and Fidin the Re uired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 r" Disposal Sites <br /> Description(Make/Yr., Color) <br /> CAL. License Na. L CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD _ <br /> For July 1, June 30,-19 <br /> � r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored w <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name <br /> R.S.or R.G.E. No. �. <br /> Test Lavation Test Date/Time' <br /> 4. JS SANITATION PERMIT Z <br /> Job Address! ovation lorz <br /> Owner' 1syzt1 cS'G {DaL Address' <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD '-SEEP'AGE PIT 11PACKAGE PLANT <br /> 11PERMANENT 11 TEMPORARY 11NEW C9 REPRIR7 p OTHER' <br /> W <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction s Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) • <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r , <br /> Where Certified <br /> Operator Name 0 w <br /> Plant Location <br /> t' No. Units-Served <br /> Plant Capacity <br /> `7. •❑ LAUNDRY For.July 1, -June 30, 19 F� ¢ <br /> T <br /> [Epumnoft� �Wmvor <br /> Ft ❑ More Than 1,000 Sq. Ft.SIZEt► � 9i� ttt wK@@�fR?Rtitt{Iui ,,,I❑ DRY C' � � - e wOf QrWhICh this p0tR1iI IA Iaat{Ad,I ohgIIrev : 3 2A�11 ti tlr�e 4!131 tti}>E.c@aist�r� : y 1`a ;�. .I certify that in the performance of the work for wfi(eh this permit is IaS9ed,.-M141=011 r <br /> Thereby certify"that I have prepared this'appiicatior'i and that the work-will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r9jes-gno re lations o S Joaquin Local Health District. T <br /> APPLICANT'S SIGNATURE X r <br /> L �,. .�. _.-.. <br /> FOR DEPARTMENT USE ONLY i x <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By'January 31 E] July 1 &ReceivedREMIT <br /> uIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE :REMITTED, AMOUNT <br /> LESS <br /> PRORATION {{ <br /> PLUS <br /> PENALTY <br /> I •" b� . <br /> OTHER f <br /> i' OTHER <br /> .5`Receipt No. -al- <br /> Permit No. ssua a-Da Mailed Delivere <br /> Received by Date d <br /> AVE.,P.O.Box 2009 5TOCKTON <br /> APPLICANT—RETURN ALL COPIES TO: " 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZ ,GA 95201 l> <br />