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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> �� APPLICATION <br /> (For Non-Transterable, Revocable,and 5uspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT t .r _.. <br /> � uQulo wasTl: <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local.Health District <br /> .I Business Name (DBA �� Address <br /> a Owner <br /> v Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Q Emergency Telephone No <br /> Contractor Licence No. . - p �/ e / �T <br /> (� .$O Title - Date f <br /> Applicants Name (Print) i - _ - ` <br /> Please check Applicable Category (1-7) and Fill In the Required Information ,x .`yE,t t' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, `June 30,`101` Disposal Sites - .1 <br /> Description(Make/Yr., Color) . <br /> Serial No, . CAL. License No. CAL. License Renewal No. <br /> Capacity �M' Gal.,Weights &Measures No. <br /> Equipment Parking Address �M <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19' <br /> No. of Vehicles Stored r <br /> No. of Chemical Toilets Stored . <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R-C.E. Name R.S.or R.C.E. No. <br /> Te t Location Ik Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location <br /> Address '� G <br /> ZSe <br /> r ❑ PACKAGE PL T <br /> PTIC TAN ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT ❑ OTHER ' <br /> 11 PERMANENT ❑ TEMPORARY NEW 11 REPAIR <br /> 5. ❑ CHEMICALTOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units I� Equipment Storage/Cleaning Location(s) <br /> kr <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, Q7 19 _ <br /> Where Certified <br /> Operator Name I' 'w- <br /> Plant Location �` ► <br /> Plant Capacity No. Units Served <br /> 7- ❑ LAUNDRY For July 1, June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., C3 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ., <br /> F4omeownarorlicens3d..ganY'asictnn:ea;z;tarsi.iasis;efcfi;:vi:;:;"'c-.-i:i'r4i«ti^t;'v�7F'fr„„ian,cif.'Sf2s^,^r'r:fGr',� icittltispermitisi55ued,lsha?Ina=rm+inyaltyt�nr=-- <br /> lit SIICiI mai?{1Er a5 t0 tt^ n^tP -?dtl S Cr�l't�?°(t$='.i - <br /> Conuactor's biA or rub-c' 7 s a <br /> "9 0 t'2Gt rq -e sass rt;;:F .-.. .,:airv�r I C.�riit� i �$IA^113 CBCRS Sl1bj2Ct tC 11 Q ^ice 1 t„3,Irl th;;tl�ri0i Ell i' :'�i7G'{;.[CrfCr'.Y�IICi;t;'i �.�,CALi to t Shdl1 <br /> employ Cin ��'IS CC1ik�f;n82'!: -= 13 <br /> 1 hereby certify that I have prep ar this application andt the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a d regulatio o the S n Joa uin Local alth Distdct„ <br /> APPLICANT'S SIGNATURE X -I ! <br /> i <br /> FOR DEPARTMENT U LY. - <br /> Fee IS DUE: ❑ ANNUALLY, ❑ PER UNIT-, ❑ PER SITE ❑ EA nua 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING R TTANCE $ AMOUNT DUE CHECKED <br /> DATE r. DATE REMITTED AMOUNT <br /> II <br /> FEE <br /> LESS F <br /> PRORATION 'II' <br /> PLUS ,I`I <br /> PENALTY 11 < <br /> OTHER <br /> OTHER I� y <br /> Y1 fi1 1� �1 Iy4 <br /> Received by ate Receipt No. Permit o. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOX 2009 STOCKTON,CA 95201 <br /> - i <br />