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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 /> y ENVIRONMENTAL HEALTH;_PERMIT <br /> ' LIQUID WASTE <br /> Application is hereb ade to carry on business in the jurisdictional area of thie_4an J aquin LocalHealth Dis <br /> y Business Name (DBA)- �� '.S�ONfy e_ Address - Z <br /> aOwner - E Address A - - <br /> J Firm Partners, Addresses and Tele one_Numbers <br /> -417 <br /> Business Telephone No fir- +D Emergency Telephone No_ �. y <br /> Contractor Licence No. <br /> t <br /> L Applicants Name (Print) � 07DaOF <br /> te Title . - -_ _ _ y <br /> Please check Applicable Category,(1-7),and Fill,in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <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' <br /> Fpr July 1, June 30, 19 y <br /> No. of Vehicles Stored fr <br /> r' No. of Chemical Toilets Stored C <br /> 3. ❑ PERCOLATION TEST " <br /> R.S. or R.C.E..Name t R.S. or R.C.E. No. <br /> Test ocation ( Test Date/Time <br /> 4. -�SANITATION PER <br /> Job AddresTlL ca �on 1 S <br /> Owner {� Hi; Address <br /> SEPTIC TANK ❑CESSPOOL__ LEACHING FIELD %SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY KNEW ❑ REPAIR ❑ OTHER , <br /> 5. ❑ CHEMICAL TOILETS for July 1,-June 30, 19 <br /> Type Construction Disposal Site - <br /> No. of Units t ,Equipment Storage/Cleaning Locations) � <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,'-:"June 30, 19 - <br /> Operator,Name - t Where Certified <br /> Plant Location <br /> Plant Capacity .,p No. Units Served 1 <br /> 7. ❑ LAUNDRY For-July.1, -June 30, 19 - m <br /> SIZE: ❑ Less Than 1,000 Sq. Ft,,�El More Than 1,000 Sq. Ft. ¢ <br /> El DRY CLEANING,-Chemicals-Used/Amount/Mo. <br /> I hereby certify that I have prepared this applicatiop-.and that the work.,Will be done in accordance with San Joaquin County <br /> ordinances"state laws, and rules and reg lations of Sar Joaquin Local Health District,- <br /> t � ¢ r <br /> APPLICANT'S SIGNATURE_ X <br /> FOR*DEPARTMENT USE ONLY,. .- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER1 UNIT ❑ PER SITE - 11 EACH ,❑ January 1 &Received By January 31; Z1 July"!_&Received.By'July 31 <br /> 'BILLING REMITTANCE' -$ }i � REMIT <br /> I -BASE EXPLANATION j DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS ! <br /> PRORATION 1 <br /> PLUS F i <br /> PENALTY <br /> OTHER <br /> ,;t,.,.,�•,c„c.,. ,ire- -.. r...+ <br /> r / � <br /> Received by Date 'Receipt No. i - Permit NoE ey Issuar"olf Mailed I Delivered <br /> APPLICANT—RETURN ALL COPIES TOc ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2001 STOCKTON,CA 95201 <br />