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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. APPLICATION (For Non-Transferable, Revocable;and Suspendable) SEPTAGE ENVIRONMENTAL HEALTH-PERMIT V 1� LIQUID WASTE Application is hereby made to carry on business in the jurisdictional area of the San Joaquin.Local klealth District. to Business Name(DBA) f/--y-rJrl�� n•Y. 'A Address�4Z z Owner. +` /// Address. - G Firm Partners, Addresses and Telephone Numbers s - aBusiness Telephone No. f .Emergency Telephone No. Contractor Licence No. LApplicants Name (Print) G t� _ _Title _int h v Date Please check Applicable Category (1-7)and Fill in the Required Information CC V.;, e: ,'; '1.0 , 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) For July 1,^ June 30, 19 -' "' Disposal Sites- - Description(Make/Yr., Color) Serial No. CAL. License No. CAL. License Renewal No. Capacity Gal.,Weights & Measures No. _ Equipment Parking Address ' t 2. ❑ PUMPER YARD ~� - For July 1, June 30, 19 No. of Vehicles Stored t No. of Chemical Toilets Stored 3. PERCOLATION TEST --a z- 5P.4 R.S. or R.C.E. Name ytctiV, (Le<4M R.S. or R.0;E. No. �� C 4 Test Location of 'Pr zest DatelTime p IOU r x.50..o �c�y►-. 19. /LR/, 4. 11 SANITATION PERMIT 4' � • 3 � moo--s�v '., � Job Address/Location >_�;U d A) G2 Owner Address CJ ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT o L ❑ PERMANENT ❑ TEMPORARY ' ❑ NEW ❑ REPAIR ❑ OTHER S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Type Construction Disposal Site No. of Units Equipment Storage/Cleaning Location(s) t 6. ❑ PACKAGE TREATMENT PLANT For July 1;.-June 30, 19 Operator Name Where Certified Plant Location _ t Plant Capacity s No. Units Served k ems+ 7. ❑ LAUNDRY Y For July 1, -June 30, 19 -€ ! SIZE; © Less Than 1,000 Sq. Ft.,' ❑ More Than 1,000 Sq. Fl.; y ❑ DRY CLEANING,Chemicals Used/Amount/Mo. } I hereby certify that I have prepared this application and that the-work will'be done in accordance with San Joaquin County ordinances, state laws,,,Zarldiptes and regulations of the San Joaquin Local Health District., L i APPLICANT'S SIG NATUREX . I - -FOR DEPARTMENT USE ONLY f Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE _ ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT i. FEE f1r-dam/ = y LESS PRORATION h10 } " PLUS D y PENALTY OTHER OTHER s Received by _ ate t Receipt No. P mit No. v Issuance Date Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201` .