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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> 1, (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> = ENVIRONMENTAL HEALTH PERMIT <br /> +i LIQUID WASTE , <br /> Application is her by made to carry on business in a Junsdictional area of the San Joaquin Lgcal Health D'strict <br /> Business Name (DB -M c Address {?( <br /> Owners , m d - _ Address— l <br /> u - - <br /> J Firm Partners,Addresses and Telephone Numbers Emergency Telephone No. - - �- <br /> aBusiness Telephone No. _ - - -- - <br /> Contractor Licence No. 3. <br /> �Applicants Name (Print) Ij. _ _ Title --- _- Date <br /> Please Check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMI�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 Ij_ Gal., Weights &Measures No._. <br /> f <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> E No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. CI 'PERCOLATION TEST I <br /> R.S.or R.C.E. Name R.S. or R.C.E.No. - --- <br /> Test Location <br /> Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Iy� Job Address/Location <br /> Owner - _ Address <br /> t 4SEPTIC TANK ❑ CESSPOOL LEAC NG FIELD SEEPAGE PIT ❑ PACKA E PLANT <br /> 06 <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER ^� <br /> S. ED 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 P LANT For July 1. -June 30, 19, <br /> Operator Name -_ Where Certified - <br /> Plant Location -- - _ <br /> I Plant Capacity_ __ No. Units Served - <br /> t 7. ❑ LAUNDRY For July 1, June 30. 19 — <br /> SIZE: ❑ Less Than 1,000 Sq.Ft., ❑ More Than 1,000 Sq. Ft. <br /> k ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - - --- -- <br /> r . <br /> I hereby certify that., have prepared this application and that.the work will be done in accordance with San Joaquin County <br /> I <br /> ordinances, <br /> Xwl and r le nd gulatio f the San Joaquin tical Health District. <br /> APPLICANT'S S <br /> FOR DEPARTMENT USE ONLY <br /> fee IS DUE:Cl ANNUALLY 1:1 PER UNIT ❑ PER SITE ❑ FACS ❑ January l 8'Recelved By January 31 El July 1 S Received By J-.Iy 31 <br /> REMIT <br /> �F.j BILLING REMITTANCE x AMOUNT DUE CHECKED <br /> BASE EXPL.ANATION DATE DATE REMITTED AMOUNT <br /> - ly *LJ5 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS I <br /> PENALTY <br /> OTHER <br /> II <br /> OTHER <br /> I C _ IHS_ °3 a p=er <br /> Fleeeiv*d by Date - Rece.pl No. - Permd No �e Da MeileG a rve*ed <br /> q <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bot 2009 STOCKTON,CA 85 <br /> 20 <br /> i J� <br />