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{ Applications Will Be Processed When Submitted Property Completed.fieSureToSign TneAppucauon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> _-LIQUID WASTE _ <br /> Application is hereby made to carry o business in the jurisdictional area of the San Joaquin LcaHealth District, r� <br /> w <br /> f,Business Name (DBA) 4A� _.Be <br /> z Owner Address <br /> a . <br /> Firm Partners, Addresses and Telephone Numbers s� <br /> a Business Telephone No. q� �0.7. _ ~:Emergency Telephone No. a <br /> ,_ �, <br /> �Contractor Licence No- f a� - - �- " . - , to <br /> Da -. ? Xl.�l� <br /> Applicants Name (Print) . __ - -. Trtie ti <br /> - <br /> Please check Applicable Category (1-7) and Fill in the Required Information. rr, .c <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) --� <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 /> Capacity Gal., Weights & Measures No. - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD +�- <br /> For July 1,: June 30, 19 —' r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ; <br /> 3: ❑ PERCOLATION TEST R ; <br /> r R.S. of R.C.E. Name t ` R.S. or R.C.E.No. <br /> Test Location € M _ Test Date/Time <br /> 4. SANITATION PERMIT >E 1 f <br /> Job Address/Location .- `- <br /> a, �• e r <br /> Owner h !�A 7P 7���aI Address <br /> j �'� ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK: ❑ CESSPOOL - ,LEACHING FIELD ❑ SEEPAGE PIT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW. ❑ REPAIR OTHER Q ^w�. <br /> 5. ❑ CHEMICAL TOILETS For July -1, -June 30, 119 <br /> S Type Construction Disposal Site <br /> No. of Units Equipment-Storage/Cleaning Location(s) <br /> 6. El PACKAGE TREATMENT PLANT For July 9k-JIB e 0, 19 S <br /> Operator Name - - - Where Certified ' <br /> ` 1 n 4 <br /> Plant Location <br /> Units Served <br /> Plant Capacity 1 <br /> 7. ❑ LAUNDRY4 For July 1,-June 30, 19 <br /> SIZE: 1:1Less Than 1,000 Sq. Ft., ❑ M_ove Than 1,000 Sq.,Ft. { <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r <br /> I hereby certify that I have prepared this application'and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I 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 /> - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED : <br /> h.. DATE DATE �RFEMITTED - ?• AMOUNT <br /> r .s . r <br /> FEE <br /> LESS <br /> PRORATION4u411 - <br /> r - <br /> PLUS _ _ <br /> PENALTY --- i <br /> ' ), •rte) �� u- � Z3•( G.r,rC./ ,=;yr•+-J r`r�, - <br /> OTHER <br /> OTHER <br /> 41 <br /> Received by ." ate Receipt No, Permit No <br /> - <br /> i Issuanc Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO- ENVIRONMENTAL-HEALTH PERMIT/SERVICES' ' 1$01 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />