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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> r Application ishereby made to carry on business in the jurisdictional area of the San Joaquin Local Health.District <br /> +n Business Name (DBA) ��,rULL 1- 9 Address /EQ- ag>d <br /> z Owner L).•Zz;E�;-_G Ute— Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> K Business Telephone No.. /!, Emergency Telephone No. y <br /> Contractor Licence No, <br /> Applicants Name (Print) - _.._. _,�..,-L.... � r- Title _" �� � -. Date <br /> Please check Applicable Category (1-7)and Fill in-the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i <br /> For July 1, - June 30, 19 Disposal Sites ... <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. . ; <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD q <br /> F For July 1, June 30, 19 <br /> No. of Vehicles Stored _ <br /> No. of Chemical Toilets Stored l �' <br /> 3. ❑ PERCOLATION TEST # <br /> R.S. or R.0-E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Locca-ttiilo}n <br /> Owner Q;n M eta— Address r .w rr �` e v� <br /> V SEPTIC TANK ❑ CESSPOOL LEACHING FIELD '❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW D REPAIR ❑OTHER o <br /> S. 1:1 CHEMICAL TOILETS For July 1, -'June 30, 19 i <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 t `+ <br /> Operator Name ° Were Certified <br /> Plant Location i <br /> Plant Capacity No. Units Served f i C <br /> 7. ❑ LAUNDRY For July 1, -June 30, 1.9 �- <br /> SIZE: 0 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ^N <br /> s �s . . s1 <br /> Mon cowrnrorticer+secta�rnt's ! <br /> n.• c3fiES1+�79Evt�f:t.t;t(J'�C£rlrf}h'7ti"ifi31:aP.SII}TtdrlGC6itIleWOrl�;�rV!±T•iCrtr,15 'ETTi111f5155L'dc�6.4.rn7 employ <br /> isha3l <br /> in such rnanner as"[o bceorne stlbjeeS 1c a r.'r � r er �['� ; <br /> s 'a33ov3FrFg: Ice is ':1a;in,the periarlrance r)i[.1@ Ncrk icr ti+rhich i..i perlt is,ssJe . <br /> t GontracSoY's hSring or sub-con r r <br /> I h&%169Ytiif#'il�st 1 �c�`haverprepared this application and that the work will be done in accordance"with San Joaquin County <br /> ordinances, state laws, and rules and re atio of the S n Joaquin Local Health District. <br /> i <br /> APPLICANT'S SIGNATURE X <br /> ' a I <br /> i <br /> ! FOR DEPARTMENT USE ONLY <br /> r - <br /> Fee Is Due: 13 ANNUALLYr ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 Q July 1 &Received By July 31 <br /> �^ REMIT <br /> BASE EXPLANATION i KILLING REMITTANCE - AMOUNT DUE CHECKED <br /> .,--t.-,-DAT•E�,e-—DATE— - REMITTED h - AMOUNT <br /> -. FEE <br /> LESS <br /> PRORATIONice, - - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER / <br /> .��•J7S -�l�al�� <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> 6 <br />