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APPLICATION <br /> Non-Transferable,Revocable,and Suspendabl!�) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Fiusiness Name (DSA)Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> PD A, i�A�. [��! r�--� Address <br /> = Owner Address <br /> c <br /> ?^firm Partners, Addresses and Telephone Numbers <br /> 3usiness Telephone No. 0 Emergency Telephone No. <br /> Contractor Licence No. <br /> pplicants Name (Print) � tc�G3 Title =%������' - Date q lX" � <br /> i -- <br /> ")lease check Applicable Category (1-7)and Fill in the Required Information <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> F <br /> escription(Make/Yr., Color) <br /> 1 <br /> erial No. CAL.License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> )quipment Parking Address <br /> . ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> F. <br /> of Chemical Toilets Stored --- <br /> 3. 11PERCOLATION TEST <br /> R.S. or R.C.E_Name R.S. or R.C.E. No. <br /> Fest Location Test Date/Time <br /> �! SANITATION PERMIT l L, <br /> Job Address/Location_ Al.1bT R �` Edd - f-Cf,4 <br /> Owner 2 U le A V/Al'i# Address y <br /> F�) SEPTIC TANK ❑ CESSPOOL J9 LEACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PLANT <br /> N PERMANENT ❑ TEMPORARY ❑ NEW DrREPAIR ❑ OTHER <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 /> F Operator <br /> Name Yvhere Certified <br /> Plant Location <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> rSIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> F <br /> I hereby certify that I have prepared this application and.that the work will be done in accordance with San Joaquin County <br /> Fidordinances, state laws, and rules and regulations of the quirt Local Health District. . <br /> APPLICANT'S SIGNATURE X <br /> FFOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑'ANNUALLY ❑ PER UNIT ❑ PERSITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> - - BASE EXPLANATION BILLING DUE CHECKED <br /> DATE DATE REMITTED - AMOUNT <br /> FEE <br /> LESS ' <br /> PRORATION <br /> - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 ' <br /> F <br /> Received by - Date Receipt No. Permit No. Issuance D e Mailed — Detirered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PER f� 1661 E.HAZELTON AVE.,P.D.Box <br /> /2009 STOCKTON,CA 95201 <br />