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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> G <br /> LIQUID WASTE <br /> Application is F�ereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) 2` L, %1 L e_cs>^c._. Address <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 5�-�g�j Emergency Telephone No. - <br /> Contractor Licence No. <br /> L Applicants Name (Print) Q d �'1� � .-> Title ^ Q� Date Pl-1 <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 /> 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 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3_Q _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. ❑ SANITATION PERMIT _ <br /> Job Address/Location 9:�5-/" <br /> Owner V. Address es niC <br /> SEPTIC TANK ❑ CESSPOOL ;__ LFJ4CHING FIELD ❑ SEEPAGE PIT ""❑ PACKAGE PLAT <br /> PERMANENT Q TEMPORARY ❑ NEW ❑ REPAIR OTHER <br /> 5. -❑ CHEMICAL'=TOILET$ For July 1, June 30, 19 V 1 <br /> Type Co�stru_ction t Disposal-Site <br /> No. of Units - Eefuipment Stora /Clean7iig Location(s) ` <br /> 6. ❑ PACKAGE1RFATMENT PLANT fFar July 1,---June 3q 19 a <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity - No. Units Served CA <br /> 7. 0-LAUNDRY For Jply 1,-June 30, 19 }} <br /> SIZE: 13 Less Than-1.,QOO Sq. Ft., ❑ More Than 1,000$q.?Ft. <br /> ❑ DRY CLEANING, Chemicals UsedLAmount/Mo. <br /> 1 hereby certify that I have prepared this application and that-the work-wiH be done in accordance with San Joaquin Pounty <br /> ordinances, state laws,and rpleo and regulati, of an Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX ' <br /> y <br /> FOR DEPARTMENT USE ONLY <br /> ',Fee Is Due: ❑ ANNUALLY ❑ PIER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE F�XPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> VTHER - - - - <br /> _OTHER <br /> Received by Date Receipt No. Permit No _ I uance ate-_. __:_Mailed--- - Delivered <br /> APPLICANT—RURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES q" •,1601 E.HA ELT_ON AVE.,P.O.Box 2009 $TOCKTON,CA 95201 <br /> ET <br />