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,T Applications Will Be Processed When Submitted Properly Completed. Be <br /> APPLICATION <br /> SEPTAGi <br /> (For Non-Transferable,Revocable,and Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry <br /> on business in the jurisdictional area of the San Joaquin Local Huh Distr t <br /> C+N1 L3 Male +'f Ilk — �5 Address <br /> yBusiness Name (DSA) ddress <br /> z Owner .�•�} -�{17 C7 �_ <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. Title er Date <br /> Applicants Name (Print) <br /> ` ' -, and FIII in the Required Information <br /> Please check Applicable Category li'7) <br /> i, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 19 Disposal Sites <br /> June 30, <br /> For July 1, - - -- i <br /> Description(Make/Yr., Color) 4 N ea _' C`ALfLicense-Renewal No. <br /> CAL. License No. _. <br /> Serial No. _ .f �' <br /> _ _'_ Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 1pf 2. ❑ PUMPER YARD <br /> kr <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored 1 " <br /> t 3, ❑ PERCOLATION TEST ,* R.S. or R.C.E.No. <br /> R.S.or R.C.E.Name _ <br /> i Test Date/Time +E <br /> Test ovation <br /> 4. SANITATION PEMIT/ <br /> V22 <br /> Job Add /Lo ion �f i - Address 1 <br /> it G `❑ PACKAGE PLANT d S" a Il*, P� <br /> Owner� � � �� - �J LEACHING FIELD " -❑ SEEPAGE PIT - � f� <br /> JN SEPTIC TANK ❑ CESSPOOL" ; ❑ OTHER 112. <br /> ' <br /> NEW �` 'REPAIR:•- -- �"'� <br /> Al PERMANENT ❑ TEMPORRRY <br /> 5, 13 CHEMICAL TOILETS For July 1,-June 30,,,19 <br /> Disposal Site'-_--; <br /> Type Construction ,r <br /> No. of Units Equipment-Sfoiage!•Cleaning�ocatiion(s), { <br /> l , <br /> 6, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,`19 - ---'Y' Where Certified � <br /> Operator Name .-- � .. . <br /> Plant Locationa,". <br /> � s No. Units ServedY <br /> {� Plant Capacity <br /> Cy <br /> 7, El LAUNDRY For July 1, June 30, 19 x <br /> # SIZE: ❑ Less Than 1,000 Sq. Ft.,-. ❑ More Than'1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r <br /> C ` <br /> 7 hereby certify that l have prepared is application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules an a lotions of th, San <br /> Jo <br /> Lo l He Health District. <br /> a <br /> v <br /> APPLICANT'S SIGNATURE X � e <br /> 4FOR DEPARTMENT USE ONLY ; <br /> Jul 1 &Received By July 31 <br /> REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE Y C3 EACH ❑ <br /> REMITTANCE 1 &Receive$d By January 31RMOU❑NT DUE CHECKED <br /> BILLING REMITT AMOUNT <br /> BASE EXPLANATION DATE DATE REMITTED <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ' OTHER <br /> k. OTHER <br /> 4 r - Receip . Permit No. <br /> ssuance Date Mailed Delivered <br /> t No... <br /> k �: Dale 1601 E.HAZELTON AVE., Bor 2009 STOCKTON,CA 95201 <br /> Re ived by <br /> APPLICANT—RETURN ALL COPIES TO: ENYIRONMENTALHEALTH PERMITISERVICES P.O. <br />