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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 2q 8 ( j v 311 <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT p ;, <br /> r � + LIQUID WASTE <br /> Application ereby made to car on bus+ s in the jurisdictional area of the San Joaquin Local Health District <br /> OBusiness Name(DBA) Address <br /> aOwner_�i'�D ,�fz/� ��C. Address <br /> Firm Partners, Addresses and Telephone Numbers F <br /> CL Business Telephone No. y�'S��.lc! Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print', a 21 Title ��� Date <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 /> 61 <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 /> l 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> k No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. yLSANITATION PERMIT �^ <br /> Job Address/Loc ion o2 6 <br /> Address <br /> Owner <br /> ❑ SEPTIC TANK- ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY >Z.NEW REPAIR OTHER 5c,,P <br /> I 5. CHEMICAL TOILETS For July 1, -June 30, 19Uj <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ,-- <br /> Operator Name Where Certified <br /> Plant Location <br /> i No. Units Served <br /> Plant Capacity <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 /> f <br /> O <br /> I hereby certify that I have prepared this ap ion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru a r tions f th an Jo uin Local Health District. <br /> 3 APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY- 0 PER UNIT ^❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Ju$y 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> t DATE DATE - REMITTED AMOUNT <br /> k <br /> 00 <br /> E FEE <br /> LESS �r <br /> PRORATION <br /> PLUS / <br /> PENALTY <br /> I <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Da Mailed elivered <br /> S "APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMIT/SERVICES 1601'E.HAZE-TON A P.O.Box 2009 STOCKTON,CA 95201 <br />