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Applications Will Be Processed When Submitted ProperlyCompleted. Besure 1001vil I <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> j` ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health hDDistrict <br /> � <br /> Or Business Name (DBA) <br /> 1D A, �Ai2. iS �O�S� �S.�Address f�• �-- ->` <br /> F Address Q4 <br /> z Owner <br /> a <br /> Firm Partners, Addresses and Telephone Number Emergency Telephone No. <br /> aBusiness Telephone No. <br /> �Contractor Licence No. Title `Cl Date <br /> LApplicants Name (Print) Q �O�L� <br /> Please check Applicable C egory (1-7)and Fill in the Re Information C3 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATI N (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License 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 <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> TesLLocIon l <br /> q, kr SANITATION PERMIT <br /> Job Address/Location I A �C L <br /> Owner Address <br /> ❑ SCEPTIC TANK [3 CESSPOOL LEACHING FIELD SPIT EEPAGE ❑ PACKAGE PLANT <br /> D-PERMANENT 13TEMPORARY ❑ NEW C REPAIR 13 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 C/1 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6• ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> Na. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> C <br /> I hereby certify that I hav repared this applicatio and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, u s and re I tions o t San J in Lo I Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee I5 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January,1 &Received By January 31 E] July 1 &ReceiveREMITd By uiy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASEEXPLANATION DATE DATE REMITTED AMOUNT 1 <br /> FEE�- a L`4��C J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHERCt <br /> tQ� <br /> Date Receipt No. Permit No. <br /> lssua ce Dte Mailed Delivered <br /> Received by 1641 E.HAZELTON AVE.,P.O.sox 2449 STDCKTON,Ca 95241 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />