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Applications Will Be Processed When Submitted Properly Completed. tae sure Io algn 11117r+HY"` " "'/1 <br /> APPLICATION �j � <br /> e SI,,.wr Non-Transferable, Revocable, and Suspendabl"i"'Rill", SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rBusiness Name (DBA) -�� �� '��Siif1� _ Address._. � �/�1�T� <br /> i Owner_-_ - - Address <br /> J Firm Partners, Addresses and Telephone Numbers -- <br /> 'a Business Telephone No. Emergency Telephone No.�— <br /> a _ <br /> Contractor Licence No. <br /> Title ^�I!G�t/T- Date � �, - <br /> Applicants Name (Print) F� v� �ao r' <br /> Please check Applicable Category (1-7) and Fill in the Required Information 1 <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, 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 J <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. - CA <br /> Test Location Test Date/Time - <br /> 4. 0 SANITATION PERMIT _ <br /> Job Address/Location <br /> Owner <br /> C] SEPTIC TANK El CESSPOOL El LEACHING FIELD El SEEPAGE PIT C1 PACKAGE PLANT <br /> ❑ PERMANENT ElTEMPORARY ❑ NEW 11REPAIR OTHER ' —z%l_�C <br /> S. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 i <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 ,r <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 --_ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ d/Amount/Mo. — <br /> v r 3 ryft` r "� " ' tnc ti.ertc-s 1 Itcent the work for which this pormit i3 i3sued,f shall not employaayperson <br /> sucft,rltan�er as.e ,rt:��5c�+rht y c <br /> 1Crn3trli<et�s h;{�rt� �r s�.'l;-'=«rstract[c 1 .,, <br /> P YDe i} o on,•:ag: "i cerfily that ill the perforntace �:!.� ,rk for r,F,ic;:this p4r,,it is issued.I siiall <br /> At11 I3 rs ras isect�,;.ot,u;rans <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, and rules and regulations of tbQ San Joaquin Local Health District. 11 COV <br /> APPLICANT'S SIGNATURE X <br /> fA4//A&. <br /> FOR DEPARTMENT USI ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jury 1 &Received By July 31 <br /> f � <br /> BILLING REMITTANCE REMIT <br /> $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuan a 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 />