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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication <br /> APPLICATION <br /> ,,.� (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> f LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ' r le s t�C:7—fC�- Address IA �. <br /> m Business Name (DBA) I� �- <br /> zOwner Address <br /> 4 <br /> c J Firm Partners,Addresses and Telephone Numbers <br /> M Business Telephone No. Emergency Telephone No. <br /> h Contractor Licence No. <br /> Applicants Name (Print) ?0 O� Title PAo0�PV4'e Date -2 5` <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> lam. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> r 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 Y <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> t= <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. <br /> Test ovation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location C - '�� O �-,-v G TOS r- <br /> Owner ! Address- ,/46 A hI A7-O /LEO •CdOPJI--Z-�, 4K g C <br /> ❑ <br /> u <br /> SEPTIC TANK 13CESSPOOL LEACHING FIELD SEEPAGE PIT ElPACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW REPAIR <br /> ❑ OTHER 4 <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 /> G ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 th Joaquin Local Health District. + y <br /> APPLICANT'S SIGNATURE X <br /> 1 .. <br /> - FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH ❑ January 1 8 Received By January31 ❑ July 1 &Received By July 31 <br /> i - - - - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS 1 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER _ �' ..•^ <br /> k OTHER <br /> 057 3 � � <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 2049' STOCKTON,CA 95201 <br />