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Applications Will Be Processed When Submitted ProperlyCompleted. BeSureToSignTheApplicallon <br /> APPLICATION <br />` 4 (Fon-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is 'dtonal area of the San Joaquin Local Health District <br /> mousiness Name (09B } <br /> ` @ Address �1 0-1- a s� <br /> ?caner Address_ -- -- <br /> F, ,n Partners,Addresses and Telephone Numbers <br /> E slness Telephone No. —3d& `r1 D 6 Emergency Telephone No. <br /> lontractor Licence No. �— <br /> plicants IN (Print) Title <br /> ease check Applicable Category(1-7)and Fi?itheRequire�1,brmafion <br /> .� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> rscription(Make/Yr..Color) <br /> F„rial No. CAL. License No. CAL. License Renewal No. <br />' Capacity Gal.,Weights &Measures No. <br /> uipmenI Parking Address <br /> ❑ PUMPER YARD <br /> i For July 1, June 30, 19 <br /> of Vehicles Stored <br /> .of Chemical Toilets Stored <br /> J. ❑ PERCOLATION TEST <br /> R.S.or R.C.F-.Name R.S. or R.C.E.No. <br /> stt Lo tion Test Date/Time <br /> L L SANITATION PERMIT <br /> Job Addre /Location 1 <br /> N Address <br /> ��EPTIC TANK ❑ CESSPOOL LEACHING FIELD ,❑, SAGE PIT ❑ PACKAGE PLANT Q <br /> Ipd PERMANENT C3 TEMPORARY ❑ NEW IITREPAIR ❑ OTHER <br /> � ❑ CHEMICAL.TOILETS For July 1,-June 30, 19 <br /> 1pe Construction Disposal Site <br /> 3.of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> perator Name Where Certified <br /> ant Location <br /> Plant Capacity ^No. Units Served <br /> } ❑ LAUNDRY For July I,'-June 30, 19 <br /> 1 IZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft: <br /> !!!LJ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin unty <br /> ordinances,state laws,and rules and gulations of the an Joaquin Local Health District_ <br /> APPLICANT'S SIGNATURE X <br /> I � <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Received y ary 3 July 1 8 leived By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S MOUNT DUE CHECKED <br /> DATE DATE REMITTE AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> N - <br /> r PLUS <br /> PENALTY <br /> OTHER <br /> �OTHER SOO <br /> Reeived by Date Recei�No. � Permit NO. - issuan a Date Mailed livered <br /> �---- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE:,P_O.Box 2009 STOCKTON.CA 95201 <br />