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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 /> .K.. — ENVIRONMENTAL HEALTH-PERMIT <br /> LIQU16*WASTE <br /> Applica ion is hereby m e to carry on busine� in the u dictional area oft Sawn,Joaquin oca ealth District <br /> L �� � - Addres« <br /> +n Business Name (DSA) `Y f`1 <br /> OwnerL c Address y" <br /> Firm Partners,Addresses a d Telephone Numbers <br /> Business-Telephone No, - Emergency Telephone No. <br /> A <br /> Contractor Licence_No. <br /> Applicants�larrie{Print1 Title Date <br /> Please check Applicable Category(1-7)and Fill In the Required Information., gid;• „ . c <br /> j1'. "❑ ?UMPE4'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. i CAL.LII nse Renewal No. <br /> hts-&-Measures-No. I •-+ ~ (—~ - <br /> Capacity-�-- -Gal;Weights- - - " <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. t❑ 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. Q SANITATION PERMIT - <br /> t Job Address/Local oD �1--fir-F) •� _ <br /> Owner .'�, l � .l h1M C -•1 Address .� >�NV%+�. <br /> C�EPTIC TANK ❑ CESSPOOL LEACHING FIELD ,�SEEPAGE PIT ❑ PACKAGE PLANT <br /> [{` ❑ REPAIR ❑ OTHER? <br /> PERMANENT,) ❑,TEMPORARY 1 NEW �-_ <br /> 5t ❑ CHEMICAL TOILETS �or'Jul 1,_June 30, 19 ' <br /> Y , i <br /> Disposal Site 4' IIS <br /> Type Construction ) I <br /> No.of Units Equipment Storage/Cleaning i-ocation(s) ) _ -- <br /> 8- ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 j <br /> Operator.Name--.• — Were'Certified <br /> Plantlocation <br /> •iPla IZt Capacity No.Units Served, . <br /> LAUNDRY For July 1,-June 30, 19 � � ~ �•-� � <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., More Than 1,000 Sq. R. <br /> fl DRY CLEANING,Chemicals Used/AmounVMo, <br /> V-1• t }' .-- <br /> "� I hereby certif e that I have prepared this application and that the work will be done In accordance with San Joaquin County <br /> 'A ordinances,. to d rules a regu tions o h_e Sa oaquin Local Health.District. <br /> APPLICANT'S SIGNATU <br /> f FOR DEPARTMENT USE ONLY: <br /> _ R <br /> ( Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 t; ❑ July 1 d Received By July 31 <br /> p t r I ! REMIT t. <br /> i BILLING REMITTANCE $ AMOUNT DUE CHECKED j <br /> BASE EXPLANATION DATE DATE REMITTED ' <br /> AMOUNT � <br /> O-O <br /> FEE ' <br /> y', 4 LESS <br /> .PRORATION j <br /> PLUS r +.. _. ���/XJ J /S I t✓ <br /> 4 PENALTY 1_ <br /> t OTHER ._ [``e 10, <br /> OTHER <br /> Received try Date Receipt No. T-,;,'r j Permit NoJi -.t„I '.I ante to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT19ERVICES "'`1601 E-HAZELT E.,P.O.Box 2009 6TOCKTON,CA 95201 <br />