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Applications Will.Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> J "' �• APPLICATION <br /> '" - (For Non-Transferable;'Revocable,and 5uspendable) SEPTAGE <br /> x i 3 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio is hyeby++.madeto carryon business in-the jurisdictional area:of the San Joaquin Local Health District <br /> Business Name (DBA) P_I F�� y IC`'� Address 5u <br /> z Owner Address. <br /> J Firm Partners, Addresses and elephone N umbers1 <br /> CL Business Telephone No.; , f Emergency Telephone No. <br /> -J Contractor Licence No. <br /> L Applicants Name (Print) Title xs Date <br /> Please check Applicable Category.(1,4) and FIII in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C <br /> For July 1, June 30.' 19 "'`- DisposaI Sites <br /> Description(Make/Yr.,Color) }' <br /> Serial,No. :A C_AL. License No. k -CAL. License Renewal No. <br /> Capacity' µ 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 /> s ; No. of Chemical Toilets Stored <br /> fb 3. ❑ 'PERCOLATION TEST a <br /> R.S. or R.C.E.Name f R.S. or R.C.E. No. �+ i <br /> WTI I �" `' � Test Date/Time A <br /> Test Location _ , <br /> 4,a 5ANITATION PERMIT J <br /> Job Address Location 6 " <br /> Owner =rt`* Address <br /> 11 SEPT IC TANK ❑ CESSPOOL X EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> © PERMANENTS . ❑ TEMPORARY ❑ e 30, 19 AI ?f OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units, Equipment Storage/Cleaning Location(s) <br /> fi. ❑ PACKAGE TREATMENT PLANT For July 1, -"June 30, 19 <br /> Operator Name 4 Where Certified <br /> Plant Location777 <br /> . -- - _ <br /> Plant Capacity _`..- µ .w No. Units Served <br /> { 7. ❑ LAUNDRY For July 1, -June 30, i9 <br /> Than SIZE: 0 Less Than 1,000 Sq. Ft., : F❑ More Than 1,040 Sq. Ft. _ - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r x r <br /> hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin County <br /> ordinances, state laws, and rules and regulations-of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY -❑ PER UNIT . '❑:PER SITE_ _❑ EACH ❑ January 1 &Received.By January 31 El July 1&Received By July 31 <br /> - T BILLING REMITTANCE $ IT <br /> ' BASE EXPLANATION a AMOUNT DUE CD <br /> DATE DATE REMITTED aaT <br /> FEE ,.:. <br /> LESS + <br /> - „ PRORATION <br /> PLUS _ <br /> PENALTY <br /> A. <br /> ..--Aa •t A ..1i <br /> OTHER <br /> } r r <br /> Re eived;by i~ ate :Receipt No.`. L Permit No. _ Issuance Date _ as d Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P. 2009 STOCKTON,CA 95201 <br />