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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..-ERMIT <br /> ii <br /> n� LIQUID WASTE , <br /> Application is hereby made to carry on business in the jurisdictional area of-the San Joaquin Local Health District,, <br /> Business Name (DBA) t Address <br /> aOwner,.0 _.. ! Address <br /> 1 Firm Partners, Addresses and Telephone Numbers - r <br /> o. Business Telephone No. _ - Emergency Telephone No. <br /> Contractor Licence No. _ <br /> Applicants Name (Print) '�` Title Date.�"�"' <br /> Please check Applicable Cate ory - ) nd Fill in e e wired Informs on <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> -For-July 1,-_ -t-. June 30, 197 I - Disposal Sites <br /> Description(Make/Yr., Color) !' <br /> Serial No. _ I. CAL. License No. CAL. License Renewal No. t <br /> Capacity _ ^ Gal., Weights &Measures No. <br /> Equipment Parking Address " <br /> 2. ❑ PUMPER YARD '! , <br /> For July 1,_ June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored if <br /> 3. PERCOLATION TEST <br /> 2 + rr 46'e- 8/8,9 <br /> R.S. or R.C.E. Name r�a w"t �:�. 5 r� t�� r _ R.S.or R.GE:No. " <br /> Test Location ����✓ !�//^' Sa/' r "Test-Date/Time - z7 &e P83D,Ai�� <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner { Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL - ❑ LEACHING'FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT fs <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 'r ❑ REPAIR ❑ OTHER r <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ° <br /> Type Construction i Disposal Site <br /> No. of Units JI Equipment Storage/Cleaning Location(s) l <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> i� 4Y- Where Certified <br /> _. - <br /> Plant Location <br /> y - Y- ND. Units Served rt <br /> Plant Capacity - """'�"'� <br /> ,7. ❑ LAUNDRY For July 1, -June 30,-19 <br /> SIZE: ❑ Less Than.-1;000.Sq:Ft ❑ Mae-Than 1,000-Sq..'FC,:" - <br /> ❑ DRY CLEANING-,-Chemicals Used/Amount/Mo. - <br /> b. <br /> 1 hereby certify that 1 have prepared this application and that the work Will be-done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulati of the n Joaquin Local Health District. <br /> :APPLICANT'S SIGNATURE X i t ► <br /> FOR DEPARTMENTUSEONLY w <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 0 July 1 &Received By July 31 T <br /> t'BA <br /> REMIT <br /> BILLI REMITTANCE $ AMOUNT�DUE CHECKED <br /> XRLANATION A -OATS - 'REMITTED� AMOUNTov <br /> FEELESS y.PRORATIONPLUS4 PENALTYOTHER -r.' �✓ <br /> OTHER <br /> 003 <br /> >• Received by Date y _F .Receipt No. Permit No. Issuance Date led Delivered <br /> STOCKTON,CA 95201 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - —`1601 E.HAZELTON AVE.;P.O.Box 2009 <br />