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xr x Applications Will Be Processed When Submitted Properly Completed. tsebore IIo alga 1 *�++HH^""•"�"' <br /> APPLICATION <br /> l (For Non-Transierable, Revocable,and Suspendable) SEPTAGE a <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Loc��ealth Djssac��s�R <br /> ,-&-, �,u j/j dy -� 5 oN Address O- /30 <br /> yBusiness Name (DBA) <br /> i, i Owner /�1 & Address <br /> P Firm Partners, Addresses and Telephone ;m%rs <br /> C Emergency Telephone No. <br /> f a Business Telephone No. j <br /> Contractor Licence No. <br /> Title Date <br /> L Applicants Name (Print) <br /> E 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) CAL. Llccnse Renewal No. <br /> Serial No. CAL. License No. — <br /> I <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> C For July 1, June 30, 19 <br /> 3' No. of Vehicles Stored <br /> I No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S.or R.C.E.Name , <br /> Test Date/Time <br /> Test Location <br /> 4. ® SANITATION PERMIT `� D <br /> Job Address/Location -3Q M tr <br /> Owner V,4W As Address <br /> ® SEPTIC TANK []'CESSPOOL Pr LEACHING FIELD ❑ SEEPAGE PIT []'PACKAGE PLANT <br /> ❑-PERMANENT ❑ TEMPORARY 29 NEW ❑ REPAIR ❑ OTHER - <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -J. <br /> Type Construction 9 Disposal Site -I <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> A <br /> Operator Name - <br /> Plant Location - - <br /> No. Units Served <br /> Plant Capacity <br /> F 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> { SIZE:` ❑ Less Than 1,000 Sq. Ft., More Than 1,000 Sq. Ft. <br /> C3DRY CLEANING, Chemicals Used/Amount/Mo. <br /> prepared this application and t <br /> I hereby certify that I have that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and s and regulatio s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �� <br /> 3Ato, <br /> i 7 <br /> j. FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRd By l July _ <br /> BASE # BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION <br /> [ DATE DATE REMITTED AMOUNT, <br /> O <br /> FEE <br /> LESS <br /> i PRORATION <br /> PLUS �� r <br /> PENALTY { <br /> r OTHER li <br /> . OTHER m <br /> 3 - <br /> E tel. .� �S. .a <br /> Received by <br /> ate Receipt No. Permit No. Issuance D Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1fi01 E.HAZELTO „P.O.Box 2009 STOCKTON,CA'_9520 <br />