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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _ APPLICATION <br /> I (For Non-Transferable Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEAL•TWPERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) V1;lC��1�N �,N�tW S­ INC Address ., 'L-10 N , �llNTE56e- 1 STO <br /> ► a Owner Yk19 CFS W0. C-,=e , Address <br /> Firm Partners, Addresses and Telephone Numbers m <br /> aBusiness Telephone No. 4�`' --. �S Emergency Telephone No. <br /> Contractor Licence No. W _ <br /> �Applicants Name (Print) Cil Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required,lnformation•, ,,FIR � - � +.� "•. �,;-. .,..Y +. ; +*) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH-VEHICLE) <br /> For July 1, June 30, 19-- ` Disposal Sites _ - _ _ . <br /> i Description(Make/Yr., Color) _ <br /> Serial No. CAL. License No. CAL. License Renewal No. i <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. ol Chemical Toilets Stored <br /> 3. PERCOLATION TEST <br /> R.S. or R.C.E. Name 1 C , R.S. or R.C.E. No. RC�7z- <br /> Test Location Z= 3 S Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner ' Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT W <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, _June 30, 19 <br /> Type Construction Disposal Site <br /> i No. of Units Equipment Storage/Cleaning Location(s) <br /> 6 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> + Operator Name Where Certified <br /> I Plant Location <br /> f Plant Capacity No. Units Served s <br /> 7. 0 LAUNDRY For July 1 -June 30, 19 <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> -�„ _ _ _ - m - -z. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> her certify that I have prepared this plicat n and that fh 'ill be done in accordance with San Joaquin County <br /> II ordinances, state laws, and rules and r la i of San Joa i Lo I Health District. <br /> F APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due; ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMlT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> -DATE DATE REMITTED - AMOUNT <br /> -FEE o r <br /> LESS 1 <br /> PRORATION r �Ip Cr <br /> PLUS + a <br /> ' r PENALTY - —� �. rI -6 ✓)1�[Lf�'. - <br /> t OTHER ` <br /> OTHER {: <br /> Received by IDate i Receipt No., Permit No, ; Issuanc Date Mailed Delivered. f <br /> APPLICANT—RETURN ALL COPIES TO_ ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />