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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />✓ APPLICATION <br /> (For Nan-Transferable, Revocable',and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica ion is hereb made t ca n bLsi ss in th jurisdictional area of ih San Joaquin Local Health District . <br /> ,,F Busines Name {DBA) Address <br /> aOwner Address <br /> J Firm Partners, Addresses anMelonembe s <br /> aBusiness Telephone No., to -Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title to r <br /> Please check Applicable Category (1-7)and Fill-in the Requiredanformation. ., , ,•, , M1 7+ <br /> 1: ELPUMPERIVEHICLE PERMIT:REGISTRATION (FOR EACH VEHICLE) `–� Zxr <br /> "`For July I.' '' -""June 3b,"19-`"� "Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. �� 'CAL. License Renewal No. <br /> " Capacity "�"�"�"`"" _ �"Ga1.`Weights &Measures No.— <br /> Equipment <br /> o,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 <br /> R.S.�or R.C.E:Name:" r 3 R.S. or R.C.E. No. <br /> Test Location <br /> �"_ Test Date/Time <br /> � <br /> 4. ❑ SANITATION PER T v , <br /> y <br /> Job'Address/ catio t� r - <br /> Own era Address Lil <br /> SEPTIC TANK EYCESSPOOL ❑ ACHING'.F ESQ ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> I]"PERMANENT 13 TEMPORARY NEW ❑ REPAIR ❑ OTHER I �1 <br /> ❑ CHEMICAL_TOILETS For July 1, Ju a 30; 19 i <br /> Type Construction s Disposal Site <br /> No..of Units Equipment Storage/Cleaning Location(s) ' <br /> 6. 0 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Op_eFator Name - - Where Certified <br /> Plant Location <br /> Plant Capacity ) No. Units Served _✓y_ <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 I e <br /> SIZE: ❑ Less Than 1,000 Sq: Ft., ❑ More Than 1,000 Sq.3Ft. " <br /> ❑. DRY CLEANING, Chemicals Used/Amount/Mo.F <br /> 13 t <br /> lfomaowrtero>lic4rtse!Arsr,;r. 1 f irk if rti l Il Ca;; Y,Ta;,rer`the ^:rcrk.fat"whirhthis perni€isissucJ,lshall incter;rloyany Pers0rl <br /> in such manner as fo Irecsre sof;;e�[ + , <br /> � . <br /> pContractor's hiring or s�orkni , y,,,,�, 'i ceri.4 that i;�the psrfpr;arca of Ilia work fdr which chis perfrit is issued,I shill r <br /> Er(lpl0y p8rS011�51J�j#;G La.4Vflrkri;?..Ii S CGIPPei u.iuil!aVLjj 0: 1 difci ilia", - s <br /> I hereby certif t I ha a lois a plicatio d t t the Vill be done in accordance with San Joaquin County <br /> --.t ordinances, s e .r a an s Q a an o ui Loca ealth District. t <br /> APPLICANT'S SIGNATURE X = <br /> I � <br /> .T FOR DEPARTMENT USE ONLY <br /> t Fee Is Due:'© '{ ❑ PER UNIT ❑ PER SITE i ❑ EACH ❑ January 1 &Received By January 31 El July i &(Received By July:31 <br /> LING REMITTANCE $ REMIT <br /> BIL <br /> BASE"' EXPLANATION 4 AMOUNT DUE CHECKED <br /> �yJ � k DATE DATE REMITTED AMOUNT <br /> I FEE +. _._ Y' L(j�' ..- F y... ..r_._j <br /> 14 <br /> � LESS /, <br /> f-'PROrtATION 'y <br /> PLUS <br /> PENALTY <br /> OTHER - aZ7 <br /> J Z..a- i� -}.r ' 1�• j <br /> .OTHER <br /> Received by I DW4f' Permit No.' I Issuance Date - Mailed Delivered <br /> STOCKTON,CA 45201 <br /> APPLICANT—RETURN ALL COPIES To: " ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 <br />