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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication <br /> ` APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ~ LIQUIo WASTE <br /> Application is hereby made to carry on busln sin the jurisdictional area of the San Joaquin Local Health District ' <br /> y Business (DBA) Address&rp- 3 <br /> Name • � � -���' <br /> I' i���Yr�c- 001, 01 <br /> - Address <br /> z Owner /� <br /> a <br /> J,Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Informationt- ,Cj,'O;o -�L Stoci ^;'1, 03.!1f. 9520&, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) F;:,_/-`tiz 09 Cortractc! Lic..r;�6Z1.J <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 /> k Capacity Gat.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD *� <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored fIK <br /> .No.-of Chemical Toilets Stored <br /> f 3. ❑ PERCOLATION TEST �i <br /> f R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. X'SANITATION PERMIT •� ' <br /> Job Addres / ocation ' <br /> Owner Address <br /> ❑ SEPTIC TANK : CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT C1 TEMPORARY ❑ NEW XREPAIR <br /> ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> F Type Construction <br /> No. of Units - Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT Fdr July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> ( Plant Location <br /> Plant Capacity Y No. Units Served _ <br /> 7. ❑ LAUNDRY For July 1,-June 30; 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> CI ,`•.f,E4sUE'S 6�>''TI_C & KIXEf+ SERVICE' <br /> 263 So. Ciro tA Stockton, Calif. 95205 <br /> i'l7.rL �ti 9 Contractor's Lic.#267174 <br /> i <br /> 1 hereby certifythatI have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r�a gulations of the San Joaquin Lo Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due- ❑ ANNUALLY ❑ PER UNIT PER SITE (D EACH ❑ January 1 8 Received By January 31 ❑-July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT E CHECKED <br /> DATE DA E REMITTED AMOUNT <br /> t FEE <br /> s - � <br /> LESS r <br /> PRORATION <br /> PLUS _ \� <br /> t PENALTY <br /> OTHER <br /> L <br /> OTHER <br /> C pate _ Receipt No. Permit No- Issuance Date Mailed Delive d <br /> Received by <br /> [ APPLICANT-RETURN ALLCOPIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES STD TON,CA 9 201 <br /> 1601 E:HAZELTON AVE.,P.O.Boz 2009 <br />