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Appiicabons Wm tie Processed wnen suommed Property comi ne sure 1 o algn I ne rappucauon. <br /> i APPLICATION <br /> L (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I - LIQUID WASTE p <br /> ILS Applicata n is/h/ere ade to car on bus ess in the jurisdictional area of the yS n Jo qu Local Health <br /> 7.�Z0� <br /> y Business Name (DBA) ^' .�. pi [J ,r Address X711// <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> IS Business Telephone No. <br /> — e-00, <br /> 6E Emergency Telephone No. d <br /> I Contractor Licence No. <br /> Applicants Name (Print) Titl, sTAGIa4'7Y`Y� Date <br /> 1.Please cheek Applicable Category (1-7) and Fill in the Required Information I ,` <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) V� <br /> For July 1, June 30, 19 Disposal Sites —. <br /> `Description(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 /> L, 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 /> LTest Location Test Date/Time <br /> 4. ff SANITATION PERMIT <br /> Job Address/Location 7,0gs,71 W <br /> Owner �y� Address - -S <br /> 6. 11 SEPTIC TANK 13 CESSPOOL I� LEACHING FIELD BISEEPAGE PIT ❑ PACKAGE PLANT C <br /> R-PERMANENT ❑ TEMPORARY ❑ NEW RIREPAIR ❑ OTHER o� <br /> 5. ❑ CHEMICAL TOILETS For July /,-June 30, 19 <br /> C <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 /> V 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 h Ve prepared this application a that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws d rules a regulati oft an J aquin Local Health District. <br /> L APPLICANT'S SIGNATURE <br /> O, <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & c ve B January 31 ❑ July 1 &Receiveo Sy'July 31 <br /> REMIT <br /> BILLING RE TTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> V DATE ATE EMITTED AMOUNT <br /> FEE <br /> L LEBS <br /> PRORATION <br /> PLUS ✓ <br /> PENALTY <br /> L OTHER <br /> OTHER <br /> LReceivetl by Date Receipt No. Permit No. Iwua e D.e iled DelivereE <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE..P.O.eon 2009 STOCKTON.CA 95201 <br />