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t A p icatlons Will Be Processed When Submitted.Properly Completed. Be Sure ToSignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br />` Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District u <br /> m Business Name (DBA) <br /> dress <br /> Ad4645 <br /> I`_ Ownern�a J d___7 Address <br /> a <br /> u Firm Partners, Addresses and Telephone Numbers (� <br /> a Emergency Telephone No.-9 57-1027 <br /> a. Business Telephone No.. .93i Q49.7 - <br /> -t <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title �Td :Date t <br /> Please check Applicable Category (1-7) and.Fill in the Required Information w r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) y4 <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 /> } <br /> Capacity. 'N Ga Weights &Measures.No. <br /> Equipment narking Address.�F - �- <br /> 2. ❑ PUMPER YARD , t <br /> For July 1, � .� .Jtine 30, 19 "° {.r 1> ; <br /> ir <br /> No. of Vehicles Stored �. <br /> s-�._ <br /> No. of Chemical Tolfets'Stored <br /> I 3. ❑ PERCOLATION TEST t I sr <br /> 1 <br /> ' R.S.+ l, R.S. or R.C.E. No. <br /> GI- <br /> ft R.S. or R. E'NameO ( i <br /> Test Location ► " Q� Test Date/Time t �� <br /> �d <br /> Q. ❑ SANITATI ON�PERMIT - <br /> ss/Location Addre ..` <br /> Owner_ ' <br /> ❑'SEPTICTANK ❑ CESSPOOLS ❑ LEACHING IELD 5E AGE PIT ❑ IEt"IAGE PLANT` 0 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19., <br /> Type Construction Disposal Site - <br /> No'«'of Units Equipment Storage/Cleaning Locations).J\ } <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> .. <br /> ' Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Th.1,000 Sq. Ft., ❑ More Than 1,000 Sq.'Ft. <br /> ' ❑ DRY CLEAN ING-`Chem_icals Used/Amount/Mo. <br /> ° <br /> IF # r <br /> i 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 rules and re ns of the San Joaq ocal Health District. <br /> APPLICANT'S SIGNATURE X ; <br /> �- - FOR DEPARTMENT USE ONLtY <br /> 71 <br /> Fee IS Due: El ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH. ❑ January 1 &Received By January 31 ❑ July 1&Received By July 31 <br /> _ - - REMIT <br /> = BASE 1 EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED ; <br /> •�, ' DATE DATE REMITTED - AMOUNT <br /> A ®0 <br /> FEE <br /> LESS <br /> s <br /> i PRORATION y _ <br /> PLUS <br /> PENALTY <br /> OTHER - - <br /> OTHER - - <br /> Received by ` Date Receipt No. Permit No ua a ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 N AVE.,P.O.BoK 2009 STOCKTON•CA 95201 y <br />