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/ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Y APPLICATION <br /> (For Non-Transferable, Revocable,=and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local,Health District. <br /> E Business Name (DBA) /�514;kt7 417, A1d'a4'> Address /Z %��_ S'7�G.�id.[� <br /> aOwner - . Address _ <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 97/' Emergency Telephone No. n r <br /> Contractor Licence No. <br /> Applicants Name (Print) DateTitle ^�Z } <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) y R O <br /> For July 1, June 30, 19 - Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, I CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures 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 Stored T <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location &/- o Al. 1A11Y 47.-7 AP/t u/ <br /> Owner Address �A <br /> SEPTIC TANK ❑ CESSPOOL J4 LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT (/1f <br /> ❑,.PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER d <br /> 5., ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> r <br /> Y Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> .6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r <br /> Operator Name Where Certified <br /> Plant Location ' <br /> Plant Capacity 1 No. Units Served <br /> 7. ❑ LAUNDRY . For July 1, -June 30, 19 7 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. Ir <br /> ❑ DRY YI697l9?dVP*% C�lemicRIs Used/Amount/Mo.e <br /> rr,cnnr� <br /> in S17Ci1 mSR;ICr @5 f0 i]Zt;^I" ,,ha t i - �.�••--1:>w-C.',:;E'. �;'Cr''.,„„•,:'�{”^nr r r,tea - i <br /> 1 :z! u , t i 1 Y mit I 1a11,o.er1 la <br /> Contras or'a 6i;:7 r, r r P y or1Y Persi:rr <br /> 1:1Ll'jimit i5 Issued.1 slia:, <br /> 4 } <br /> 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 regulatio San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> - --« FOR DEPARTMENT USE ONLY <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 f <br /> BILLING REMITTANCE $ REMIT <br /> RASE" EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT/ <br /> kk <br /> FEE -110 <br /> I <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY - .•. ., ;- - , <br /> OTHER- <br /> ' - <br /> OTHER h. ' <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AYE., .O.Box 2009 STOCKTON,CA 95201 <br />