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Applications Will Be Processed When Submitted Properly Completed. BeSureTo Sign 1neAppucauvn. <br /> APPLICATION <br /> TM e (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> 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 District <br /> Business Name (DBA) el/ eP SP"'i" i?/c.. Address _ -� ' ��t� /� <br /> z Owner 60wei R. l$' --IF A.TAddress .r-?3 _ �T /tc ►¢�� <br /> a ^� yid <br /> a Firm Partners, Addresses and T lephone Numbers CF <br /> a Business Telephone No. rf -��� Emergency Telephone No. <br /> a <br /> Contractor Licence No. �` a ��Q <br /> Applicants Name (Print) s & Title r�3 Date <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) <br /> ' CAL. License No. _CAL. Lic�nse Renewal No. <br /> Serial No. <br /> Capacity -;r Gal.,Weights& Measures No. <br /> Equipment Parking Address Nip", <br /> 2. ❑ PUMPER YARD, t � # <br /> For July 1, June 30, 19— �►" t' " <br /> No. of Vehicles Stored ' <br /> No. of Chemical Toilets Stored ' <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 Addres/Location li)2QU1 SAW it oft Te C — <br /> Owner , Address GO F '� Tc p <br /> SEPTIC TANK ❑ CESSPO RD LEACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PLANT r <br /> ❑ PERMANENT [] TEMPORARY M NEW 1 ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction V-Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -'June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <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 /> 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, n rules and regulatio s of th San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PEA UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PWS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. ssuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTTO�N,CA 955201 <br /> -'/-2 f,*o e2 z64, f <br />