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A_ppl ations Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ' (For Non-Transferable, Revocable, and Suspendable) <br /> -SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> �x <br /> y LIQUID WASTE k, <br /> ^' Application is..hereby�made to carryon business in the jurisdictional area of the San Joaquin Local akth District <br /> y Business Name (DBA)�, �'� GAF�FsF .Address S75D 'amu yd <br /> z Owner Address <br /> 4 <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. �G�33'/O Emergency Telephone No <br /> -J Contractor Licence No. <br /> Applicants Name (Print) Title &&/yC!e- Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) - <br /> CFor July 1, June 30, 19 Disposal Sites Y <br /> Description(Make/Yr., Color) �._. <br /> Serial No. CAL. License No. ... CAL�L•-icense 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. of Chemical Toilets Stored �• V <br /> 3. 11 PERCOLATION TEST _ .- rte- _-N �' <br /> R.S. or R.C.E. Name R.S. or R.C.E. No <br /> ( Test ocation "} Test Date/Time ' <br /> 0. <br /> 4. SANITATION PERMIT 'y <br /> Job Address/Location Q4;2O S �s�L;E'EN L44 a <br /> I O ner -SA/� .- _ -._L - .. -- Address �. <br /> .a <br /> SEPTIC TANK ❑ CESSPOOL ']gLEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY '❑ NEW , ❑'REPAIR ❑TOTHER <br /> I 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r- <br /> R Type Construction . - — Disposal Site <br /> No. of Units 1 Equipment Storage/Cleaning Location(s) <br /> F 6. IJ 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 /> 1 - <br /> i - w <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d rules a regulations of the San Joaquin Local Health District. <br /> e � <br /> APPLICANT'S SIGNATUREX, -- <br /> _ <br /> * } FOR DEPARTMENT USE ONLY , lbi413— / <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31- <br /> REMIT <br /> 'BASE rXPLANATIONjI BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED- <br /> DATE ;j DATE t REMITTED AMOUNT <br /> FEE <br /> LESS ` R <br /> PRORATION I <br /> .41 <br /> PLUS <br /> PENALTY I ~ 1V A v 1,t,.i! 1 <br /> OTHER' <br /> OTHER , * - - - <br /> Received by Date € Receipt No. Permit No. Issuance Efate Mailed Delivered - <br /> Ii. APPLICANT—RETURN ALL COPIES TO: -;i ENVIRONMENTAL-HEALTH PERMIT/SERVICES 16131 E..HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA� <br />