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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �j APPLICATION <br /> Ir (For Non-Transferable,Revocable, and Suspendabie) SEPTAGE <br /> s ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE` <br /> Application h rmade C rryGRISl ss in the jurisdictional area of the San Joaquin,Lo Health District <br /> rBusiness N (DBA} Address— <br /> z Owner Address X _ <br /> J Firm Partners, Addresses and Telephone Number <br /> aBusiness-Telephone.No._._. j � ,.; Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) _ Title �a�' +- Date <br /> Please check Applicable Category (14)and Fill in the Required Information a , <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,-- June 30, 19 _ .7 DisP osal`.Sifes <br /> Description(Make/Yr., Color) <br /> Serial No.-- ----L—CAL-License-Nb-- tib, -- -CAL.-License-Renewat•No..r - ----;-- <br /> Capacityl Weights & Measures No. <br /> Equipment Parking'Address___J5_' 1 <br /> 2. ❑ PUMPER YARD _ <br /> For July 1, 4"Ju e 30,'9 <br /> No. of VehiclesVii:Stored <br /> .E..� <br /> No. of Chemical Toilets Stored �yV <br /> 3. ❑ PERCOLATION TEST-.-" <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> 'Test Location t Test Date/Time <br /> 4.,Z�SAwNITATION PERMIT _ `` <br /> Job Address/Location �� �Ile r <br /> Owner alp Address <br /> a <br /> CJZ—SEPTIC TANK 1:1 CESSPOOL % EACHING FIELD E] SEEPAGE PITa' ❑ PACKAGE PLANT -• <br /> �.. y. <br /> �ERMANENT ❑ TEMPORARY t O-NEW r �= <br /> REPAIR ' * THER X (2- c� <br /> Qa(�p � <br /> 5. -❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type-Construction. Disposal Site. -- -' <br /> No-of Units Equipment Storage/Cleaning Locations) <br />! 6. -❑ PACKAGE TREATMENT PLANT For July 1, -June 30,19 ' C" <br /> Operator Name -- ./Where Certified , I ' {A <br /> Plant Location t ` <br /> Plant Capacity No. Un{ts Served' f rr <br /> � { ! 3 I <br /> 7.10 LAUNDRY—For July 1.,�June-30,.19. - - ,: <br /> ISIZE7 ❑ Less Than 1,000,Sg:-Ft.,' ❑ More Than 1,000 Sq.-Ft. <br /> 11 DRY CLEANING, Chemicals Used/:Amo-uhtlMo: <br /> - <br /> >- <br /> j /X ) `6 <br /> I hereby certify that I'have p r d t ca'on an that the work will be done in accordance with San Joaquin County - <br /> € ordinances,state laws, an ul nd ations the n Joa n'Local Health District. f <br /> !n fi <br /> APPLICANT'S SIGNATURE X ' ' <br /> Vi <br /> FOR DEPARTMENT USE ONLY . <br /> aI <br /> Fee Is Due: 171 ANNUALLY C3 PER UNITS_. ❑ PER SITE ❑4EACH El January 1 &R Gfi/dBy January 31 ❑ July 1 &Received By July 31 <br /> BILLING r REMITTANCE $ - REMIT <br /> { <br />' BASE EXPLANATION " AMOUNT DUE CHECKED <br /> ti DATE r` .DATE ,REMITTED "�' - AMOUNT <br /> FEE F. -1'L4 .F. - .. .;... - - 199 <br /> . S ..... <br /> LESS ! 1 <br /> PRORATION <br /> PLUS tb d+ <br /> PENALTY <br /> OTHER <br /> I OTHER _ _ _ .•I• + <br /> Received by Date Receipt No, Permit No, Iss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: i^ENVIRONMENTAL HEALTH PERMIT/SERVICES '1eel E.HAZELTON AYE.,P.O.Boy 2009 STOCKTON,CA 95 <br />