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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. - <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ,L\ ENVIRONMENTAL HEALTH PERMIT <br /> /� 11 LIQUID WASTE <br /> Application i hereby ma to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> In Business N m it Address 17OT S {' <br /> Owner - Address—�� -� <br /> u Firm Partners, Addresses and Telephone Numbers <br /> K Business Telephooe No. 4/G ' S-'/i Z Emergency Telephone NQ. <br /> Contractor Licence No. G <br /> Applicants Name (Print) Title E-- Date /z, j <br /> Plesse 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. CAI.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. ❑ 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 PER IT /� .� .� <br /> Job Address/Locatio �T�'V� CS LI ���r3"�� �jv9oa AD 5 <br /> -Owner J ywN _r B T 8�� Address I - <br /> SEPTIC TANK ❑ CESSPOOL M LEACHING FIELD SEEPAGE PIT ❑'PACKAGE PLANT 0P <br /> ,-TGA PERMANENT ❑ TEMPORARY -Z2 NEII- - ❑ REPAIR ❑ OTHER 4; <br /> 5. CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site — <br /> No.of Units Equipment Storage/Cleaning Location(s) - <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified - <br /> Plant Location —-- <br /> Plant Capacity No.Units Served ---- <br /> +,?�-=OLAUNDRY For July 1,-June 30, 19— <br /> SIZE: <br /> 9 SIZE: ❑ Leas Than 1,000 Sq..Ft.; ❑ M9AThan`T,060 Sq.FL ' <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. t <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, andrl�eld regul ions o he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �/ 'l <br /> FOR DEPARTMENT USE ONLY - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July i A Received By July 31 <br /> REMIT <br /> BASEEXPLANATION BILLING REMITTANCE E AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 5 C \f <br /> LESS <br /> PRORATION' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit Na. I uan Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 7807 E.IiALELTON AVE.P.O.BOK'l00a STOCKTON,CA e5R01 <br />