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Applications Will Be Processed When Submitted Properly Completed. a Sure <br /> y APPLICATION! <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl icati is hereby made to car on b si ess in jurisdictional area of the 5g1 qui Local Health District <br /> �A Q�o I [�S �17G� 2 Address <br /> N Business Na (DBA) �� <br /> x Owner ceg G, Address <br /> a <br /> J Firm Partners, Addresses and elephone Nu i bers <br /> IL <br /> Business Tekephone No. ai Emergency Telephone No. <br /> }_ Contractor Licence No. <br /> 4m CAR at/ Title ����2 Date <br /> L Applicants Name (Print) <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) CAL. Ui':nse Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity <br /> Gal., Weights &Measures No. <br /> , <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 R.S.or R.C.E. No. <br /> R.S. or R.C.E.Name I <br /> Test Location T�st Date JA "'//�T,'Ime <br /> � BSMG✓? et4,"­ <br /> 4. ❑ SANITATION PERMIT �to OuvyTt�l,u <br /> Job Address Lo ation �f <br /> I Owner XI�le 6, Address r <br /> ❑ CESSPOOL LEACHING FIELD El SEEPAGE PIT C3 PACKAGE PLANT <br /> SEPTIC TANK ❑ � <br /> ❑ PERMANENT ❑ TEMPORARY NEW C] REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July I,'-June 30, 19 <br /> Type Construction. I Disposal Site <br /> No. of Units ;Equipment Storage/Cleaning Location(s) C <br /> 6. ❑ PACKAGE TREATMENT PLANT. For July 1, -June 30, 19 Where Certified c <br /> Operator Name <br /> 1 Plant Location <br /> l No. Units Served C <br /> k Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 11 Less Than 1,000 Sq. Ft., 11 More Than 1,000 Sq. Ft. `J <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that l have prepared this application and that a work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an es and reg ul 'ons of San Jo uin Local Health District. <br /> 4 _ APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> -Fee Is Due:'❑ ANNUALLY 0 UNIT I!X-PER•SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED' <br /> BASE EXPLANATION DATE D TE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> .PENALTY <br /> OTHER <br /> OTHER - <br /> Inr-� �0 7 d 3 �-S9 } n �l <br /> Date Receipt No. Permit No- issuance Aate Mailed Deliver <br /> fr Received by .r <br /> }= APPLICANT—RETURN ALL COPIES TO:, - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 .STOCKTON,�C9r1D{ <br />