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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION- <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is eby made to ca ry on b siness in the[urisdictional area of th n aquin Lo aJ ti�alth i t:ic <br /> y Business Name (DBA)_ ��l� tS ��tls rte, V /Ir,oc G <br /> _ Address_ <br /> a Owner Address �r T <br /> J Firm Partners, Addresses and T e hone N tuber <br /> a Business Telephone No. . . Emergency Telephone No. <br /> Contractor Licence No. �j - <br /> L Applicants Name (Print) Title Date <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 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. - • GAL. License NO., - CAL. License Renewal No, <br /> Ca acit I- a �. .. ' . 4'; <br /> p Y T <br /> Gal., Weights'& Measu(es 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 Stoted <br /> 3. ❑ PERCOLATION TEST �,' d �' s `"' <br /> R.S. or R.C.E. Name �< R.S. or R.C.E. No. <br /> Test°cation ^-- - - Test Date/Time d <br /> 4. IAi SANITATION PER I , <br /> Job Addre ocation <br /> 0 ner o �Rddress 7� e <br /> Ip1SEPTIC TANK 0 CESSPOOL LEACHING FIELD ISI,SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY KNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> • a <br /> No. of Units Equipment Storage/Cleaning Locations) ; <br /> B. ❑ PACKAGE TREATMENT PLANT For July,1, June 30,E19. _ t <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 T411an._1000 Sq. Ft. <br />—0:DRY CLEANING, Chemicals Used/Amount/Md.. � <br /> yF <br /> J <br /> I <br /> I 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 r sand re ul ions of th Joa ui Local Health District. <br /> APPLICANT'S SIGNATURE X y <br /> r 7 <br /> FOR DEPARTMENT USE ONLY <br /> .w Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 1:1 July 1 S Received By Juiy 31 <br /> BASE <br /> BILLING REMITTANCE $ REMIT - <br /> { EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS ' <br /> PRORATION _ U� <br /> PLUS U <br /> PENALTY - <br /> OTHER „ <br /> bw <br /> OTHER <br /> Received by Date i Receipt No. Permit No suance Dale Maned Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT%SERVICES 1601 E.HAZELTON AVE.,P.O.Bow 2009 STOCKTON,CA 95201 <br /> fi <br /> f � <br />