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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - " <br /> APPLICATION 6s� <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE 1 <br /> ENVIRONMENTAL HEALTH PERMIT / f <br /> LIQUID WASTE <br /> Application is h reb made to carry on business in the jurisdictional area-of the San Joaquin Local Health District <br /> �Business Name DBA �. L IE <br /> Owner �- 11��G IP Address. <br /> Firm Partners,Addresses and Telephone Numbers n� ` <br /> ,v1 ix <br /> Business Telephone No.—- S.SS �iac.� j J - .Emergency Telephone No. <br /> Contractor Licence No. 5. <br /> L Applicants Name (Print) „,4, iLL _Title a-� � - Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE-PERMIT REGISTRATION(FOR EACH VEHICLE) + <br /> For July 1, June 30. 19-- - Disposal Sites �;JI <br /> Description(Make/Yr.,Color) -t1 <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 /> ” i 1 <br /> For July 1, June 30, 19- <br /> No. <br /> 0, 19No.of Vehicles Stored - <br /> } <br /> ,No.of Chemical Toilets.Stored <br /> 3. ❑ PERCOLATION TEST ""` ; 1 <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. j <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT p <br /> Job Address/Location 5 t` <br /> Ow er ' � i I �'S� Address.- <br /> IT SEPTIC TANK ❑ CESSPOOL 2"LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT TEMPORARY [],NEW t ❑ REPAIR _Q_OTHEFi;_� <br /> S. CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type;Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> LA1 r. <br /> 6. ❑ PACKAGE TREATMENT PLANT For JUIy 1,_June 30,-`19 <br /> Operator-Name Where Certified - <br /> Plant Location r t t <br /> Plant Capacity C ' ( 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 /> 4 <br /> 13 DRY CLEANING,Chemicals Used/Amount/Mo. <br /> t <br /> f I hereby certify thaT'{t~va e`prepared this applic to Ion'and that the work ill e6 done in accordance with San'Joaquin County <br /> ordinances,state laws;and rules and regul ions df the San.Joaquin Local Health District. <br /> - <br /> APPLICANT'S SIGNATURE X <br /> - - FAR.DEPARTMENT USE ONLY4 <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER S.UE, :❑ EACH ❑ January 1&Received ByJan ary 31 ❑ July 1&Received By July 31 <br /> 1 <br /> IL 'F ti'rREMITTAN � S \ REMITIr <br /> BASE EXPLANATION .� AMOUNT DUE ifk CHECKED <br /> - .+DATE •, OAT REMITTED d AMOUNT di <br /> FEE.. 4-53 <br /> Vie, ti <br /> I_. <br /> LESS ' { i _� <br /> PRORATION r Sq,jam f. - <br /> PLUS ; I r t <br /> PENALTY' <br /> -OTHER <br /> t . : ,. 'moi.' �j•+�.�;. - ��,' _ .. • <br /> Received by Date Receipt No. Permit No. Is uance to Mailed Delivered <br /> APPLICANT—RETURN ALL tr`OPIEI�TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1901 E.HAZELTON AVE.,P.D.Bot 2009 STOCKTON.CA 96201�J <br />