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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> f (For Non-Transferable, Revocable, and Suspendable) SEPTAGF <br /> Y` �� ENVIRONMENTAL HEALTH PERMIT <br /> ;0 LIQUID WASTE <br /> Application is hereby ade to carry on bpsiness in the jurisdictional area of the San Joa uin Locpl Health District / <br /> y Business Name (DBA)��-Z-_ �T���d L L/-'�r(X0"-75 Address �� e� /���� l��f S -T�¢�'Vf��� <br /> i Owner Address ^A `f'rf°F.�LD 1 /.(A/w6Qfid- C11. "'/y <br /> Firm Partners, Addresses and Telephone Numbers %'!�z n�' <br /> aBusiness Telephone No. _ - Emergency Telephone No <br /> Contractor Licence No. -_- <br /> a Applicants Name (Print) .rli U� us Title ` � - * C� Date ?L <br /> 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 /> Dekcription(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. 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. heroical Toilets Stored <br /> 3. XPCERCOLATION TEST <br /> R.S. or R.C.E. N / _ R.S. or R.C.E. No. <br /> Test Location ��f�F`���?i Test Date/Time Y+ �G' i�/'� r gk> <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location _ - <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ 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 /> Operator Name - -- Where Certified <br /> Plant Location — — <br /> Plant Capacity No. Units Served <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 hereby certify that I have epared this licatipn and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a (les an re ations Za <br /> Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X .--- — — <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> 7t1G1'iju1vT� <br /> -- <br /> FEEZa <br /> LESS <br /> PRORATION -_ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by 0 Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />