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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 /> LIQUID WASTE <br /> f Applica on is hereby made to W on businesg in the juns lctional area of thsSa ,J a�ui�n Local a th Di trict <br /> rn BusinessI,Name (DBA) e� 1 �T^ t .( �� '�� 66 Address <br /> aOwner Li r/y � ,�: Address <br /> J Firm Partners, Addresses anTelephone Numbers <br /> a. Business Telephone No ' � zl(c, �-�• Emergency Telephone No. T <br /> Contractor Licence No. _ <br /> L A ficants NameI. l :.Title..1C - - 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 /> - - f <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. ,CAL. License Renewal No. <br /> Capacity"""�"""'"""'""'"""—"GaL�Vlleights'&'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. CI PERCOLATION TEST <br /> R.S.or R.C.E. Name ! R.S.or R.C.E. Na. <br /> Test Location Test Date/Time is <br /> 4. ❑ SANITATION PE MIT # \ <br /> i Job Add ess/Location r\ <br /> Owner, 9 y Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT {❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY9NEW REPAIR # ❑ OTHER t <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction } Disposal Site I <br /> No. of Units Equipment Storage/Cleaning-Location(s) t <br /> 6_i O PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r <br /> Operator Name Where Certified ' <br /> Plant Location - + <br /> Plant CapacityIi No. Units Served <br /> 7:_❑ LAUNDRY For July"1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000qLSc Ftp 13 More Than 1,000 Sq. Ft. � <br /> ❑ DORY CLEANING,Chemicals Used/Amount/Mo. r <br /> hereby ertify:that'1 have prepared this application and that th6'work will be done in accordance with San Joaquin County <br /> ordinanc s ateslaw , d rues and regulations of San Joaquin Local Health District. <br /> APPLICANT'S SIG NATU <br /> a _ , <br /> FOR DEPARTMENT,USE ONLY w <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT_ , 0-PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July.31 <br /> I <br /> REMIT <br /> ', BILLING REMITTANCE �$ - '• <br /> BASE EXPLANATION. • AMOUNT DUE CHECKED <br /> I DATE DATE -REMITTED AMOUNT <br /> [� <br /> FEE <br /> LESS <br /> PRORATION A 0 - - - <br /> PLUS <br /> PENALTY 319 <br /> 1 OTHER �� \ % <br /> OTHER r. l 1 - <br /> m <br /> Received by Date Receipt No. I Permit No. iltsuance Date Mailed Delivered' <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITISERVICES' �T1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95281 <br />