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Applications Will Be Processed When 5ubmitte ro <br /> APPLICATION <br /> (For Non-7ranslerable;Revocable;'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ere y made to carry,on business in the jurisdictional area of the San Joaquin Local Health District.. <br /> Address . <br /> 4 Business Name (DBA) _ Address - <br /> aowner-------- - <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone Na Y <br /> a Business:7elephone No. <br /> Date j <br /> Contractor Licence No. -� Ole Title ' <br /> LAPPlicants Name (Print) <br /> Applicable Category (1,-7)and Fill in the Required Information <br /> Please check App' FOR EACH VEHICLE} - <br /> 1• ❑ PUMPER VEHICLE PERMIT REGISTRATION ( _ <br /> For July 1, Julie 30, 19 <br /> Disposal Sites' <br /> r� CAL.License Renewal No. <br /> Description(Make/Yr., Color) ( CAL. License No. <br /> Serial No. <br />` Gal.;Weigh &Measures No. <br /> Capacity <br /> i Equipment Parking Address <br /> 2, ❑ PUMPER YARD h . <br /> For July 1, June 30, 18 I I �L <br /> No. of Vehicles Stored i <br /> t. <br /> No. of Chemical Toilets Stored k{ <br /> g. ❑ PERCOLATION TEST R.S. or'R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Lac n ) <br /> { 4• LhISAINITATION PERMIT <br /> Job Address/Location4. Address ❑ PACKAGE PLANT <br /> Owner r LEACHING FIELD ElSE AGE PIT <br /> ❑ SEPTIC TANK ❑ CESSPOOL t ❑:OTHER _ <br /> ❑ PERMANENT ❑ TEMPORARY (. <br /> 5• ❑ CHEMICAL TOILETS For July 1, -June 30, 1D'Isposal Site ----- "' <br /> i f f- <br /> ' Type Construction : ` <br /> No. of Units ti Storage/Cleaning Location(s) _fy ,1 40 <br /> \3 <br /> S g• ❑ PACKAGE TREATMENT PLANT For July.1, -June 10, i9 `, �-Where Certified R <br /> Operator Name <br /> t Plant Location ? 1 No. Units Served <br /> Plant Capacity1 <br /> 7• ❑ LAUNDRY_FJuly 1,or . -June 30, 9} —� <br /> �1,` ❑ More Than 1 000 Sq. Ft <br /> SIZE: 0 Less Than 1,000'Sgt'jti 4... I <br /> DRY CLEA'N1NG?�Cfemicals Used/Amount/lvlo. <br /> 4 c 1 t cation and that the work wilt be done Inaccorda'ce with San Joaquin County <br /> I hereby certify that I have.prepared this app <br /> ordinances state laws, and rules and reg �tlo of the San Joaquin Loc 1 Health District. <br /> F APPLICANT'S SIGNATURE X ., 'Y <br /> FOR DEPARTMENT,USE-ONLY """`"""! <br /> : Jul 1 A Received By July 31 <br /> ❑ January 1 &Received By January`31 Y - <br /> (] PER SITE ❑ EAGH• w _. 4 - REMIT <br /> Fee IS DUB: ❑ ANNUALLY •❑ PER_U_N17: �.. - CHECKED <br /> a ' REMITTANCE $ AMQU.HT DUE <br /> BILLING s,,, -- AMOUNT <br /> y BASE i•,r.y EXPIL ION I DATE DATE . <br /> k FEE \�1i''� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER .., <br /> l OTHER c- <br /> fF Mailed Delivered. <br /> • Permit No. lssuan a Date , <br /> Date Receipt No. 1601 E.FIAZELTON AVE-,P.O.BOK 2009 STOCKTON,CA"I T„ 7 <br /> Received by /�`rrSll��✓_ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERNIITlSERYICES <br />