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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTheApplication. <br /> / -3a 2. 4 APPLICATION <br /> . (fot7Non-Transferable;Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appllcation is?reby made to ca on business in the jurisdictional area of the San Joaquin Local.Health Di riot <br /> to Business Nam DBA} Address 4 <br /> aOwner— n1 Address �• <br /> Fi01 <br /> rm Partners, Addresses and T le hone Numbers <br /> a _ Emergency Telephone No. <br /> CL Business Telephone No. - <br /> 4 <br /> a Contractor Licence No. '' I - J <br /> CIA <br /> LApplicants Name (Print} <br /> Title Date_ ^ ;� _ <br /> Please check Applicable Category (1,7)and Fill in the Required InformationCR <br /> 1. I] PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> l Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address 141 <br /> 2. ❑ PUMPER YARD <br /> fFor July 1, June 30, 19 <br /> +tNo. of Vehicles Stored _ <br /> l�or of Chemical Toilets Stored <br /> 3. PERCOLATION TEST } <br /> R.S.or R.C.E. No. <br /> R .�o.,�rr,R.C.E.Name . <br /> Test%ILQcation Test Date/Time <br /> 4. 11 SA�NI. ATION PERMIT II <br /> Job Addres Ncation ! . <br /> Addr ss+- <br /> Owner S <br /> ❑ SEPTIC ��ANK ® CESSPOOL 13 LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> 141V, 11 OTHER <br /> PERMANENT 1:1 TEMPORARY ❑ NEW REPAIR <br /> 115. 13 CHEMICAL TOILETS For July 1, -June 30, 19C � <br /> _ ,. <br /> Type Construction Disposal Site <br /> No. of Units -�S- Equiprnent Storage/ Cleaning Locations) t <br /> 6. ❑ PACKAGE TREATMENT PLANT For,July 1,-June 30, 19 -� <br /> Operator Name <br /> Where Certified '61b ts <br /> r Plant Location <br /> �" � ';, <br /> 4. Plant Capacity � No. Units Served <br /> " 7. ❑ LAUNDRY For July ;�*dune"-30�19 <br /> f <br /> { SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than'11,000 Sq: Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> + , ;� _ <br /> I hereby de ify that I e pr1pae d this application 'and that the work will-be done in accordance with San Joaquin County <br /> ! Drdinanc�s, tate la s, an rules andrr� ulat sof aquin Lacal Health District. <br /> d APPLICANT'S SIGNAT7RE X' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. A R SITE ❑ EACH ❑ January 1 &Received By January 31 El July 4 &Received By <br /> July'31 A <br /> - REMMIT <br /> A ;` BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - BASE +'EXPLANATI. -!I DATE DATE - -REMITTED AMOUNT <br /> =Fj - <br /> LESS <br /> e <br /> FEE y . <br /> \I PRORATION <br /> PLUS �. <br /> PENALTY <br /> OTHER <br /> OTHEfl - - <br /> Received by Date Receipt Na Permit No. <br /> Is Date ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 160 �ELTONIAVE .Box 2409 STOCKTON,CA 455111 <br />