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a Applications Will Be+Processed When Submllted Properly Completed. BeSureToSign IneAppucanvu. + <br /> APPLICATION <br /> - 5r <br /> f (For Non-Transferable, Revocable, and 5uspendable) SEPTAGE �� l <br /> ENVIRONMENTAL HEALTH PERMIT r <br /> T q <br /> LIQUID WASTE <br /> Applicatio er b m de to car on bL�siness in th yurisdictional area of the quilpkjo�i each Dish 41� - <br /> r Business N (D8A} <br /> S Ix�I1��S flCK4coC ���— Address 11�� 1I��1 <br /> a �„� <br /> 4 Owner ! t ddress <br /> Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephone No, t <br /> E Business Telephone No. <br /> Contractor Licence No. Date <br /> Applicants Name (Print) �`"t Title <br /> Please check Applicable Category(1-7) and Fill in the Required Information r <br /> i. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. Lice,se Renewal No. <br /> Serial No. CAL. License 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. ❑ PERCOLATION TEST -.� <br /> R.S. or R.C.E. No. O <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. 2 SANITATION PERM laiyA £ U5�M1.7.Y AVB <br /> Job Address/Location <br />' Owner Ge"C P -'SA y � `� Address C <br /> Ig SEPTIC TANK ❑ CESSPOOL (ja LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT {/J <br /> ❑ PERMANENT ❑ TEMPORARY W NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 160( .9� <br /> Type Construction Disposal Site '} <br /> No. of Units Equipment Storage/Cleaning Location(s) /b <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 II <br /> Where Certified _ <br /> Operator Name <br /> l Plant Location <br /> 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 /> I <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 SJoaquin Local Health District. <br /> APPLICANT'S SIGNATURE X j jZ <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> f By J <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t &Aeceiv REMITuIy 31 <br /> f BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE EMITTED AMOUNT <br /> FEE <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER' '4 - <br /> y i 11 <br /> I Received by <br /> ate Receipt No. Permit No. Issuance Date ailed Delivered F r <br /> 6 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE., .O.Box 2009 STOCKTON,CA 9520. f <br />