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Applications Will Be Processed When Submitted Property t;ompleteu. o� aui­ �•y•• •• - -- <br /> APPLICATION / <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> I <br /> 'A Business Name (DSA) ��� ------ Address <br /> z Owner ,.�... _�c�G6�'�.0---= Address <br /> c <br /> u- Firm Partners, Addresses and Telephone Numbers - <br /> aBusiness Telephone No. S-_ Emergency Telephone No. . <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date--�— <br /> Please check Applicable Category (1-7)and Fiil.in the Required Information <br /> 1. ❑ PUMPER VEHI6LE PER MtT�GISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites _- �✓ <br /> Description(Make/Yr.,Color) CAL. License Renewal No. + S <br /> Serial N6 _ CAL.License No. {I <br /> Capacity; Gai., Weights &Measures No. - - - <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD (y <br /> For July 1, June 30, 19 .No.of Vehicles Stored - <br /> No. of Chemical Toilets Stored ` <br /> 3. ❑ PERCOLATION TEST t <br /> R.S. or R.C.E.Name _ _ R.S.or R.C.E.No. - <br /> Test Location _ Test DateMme <br /> 4. ❑ SANITATION PERMIT 143 <br /> Job Address/Location <br /> Owner 'T_n✓ Address �`P <br /> SEPTIC TANK 11 CESSPOOL LEACHING FIELD 13 SEEPAGE PI7 13 PACKAGE PLANT <br /> PERtvIANENT ❑ TEMPORARY ❑ ElREPAIR ❑ OTHERNEW r 'l <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19_ W <br /> Type Construction _ Disposal Site <br /> No.of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1.-June 30, 19 <br /> _ Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> -- <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 /> aeon:^'fgn�ttr+xtrr`t tFefNtbwln3:'I'yRilythat inthe perforrrtanceefttrrworkfatwhich thisiIeunitisi ',fled,lsh2lt❑ntcmplmyg <br /> raner <br /> Home awl <br /> I. <br /> in such manner as to twoln?s7b!,cf;r,w t;::rat;'s q1;r,_, - ^,'.ion'aws of Ca!iforlTia f etrGty tR2t is the pertormar of ttt rc:k ter "ch til.;herr t <br /> Coritractor's Nrir� o: suh-eot•trc ':r;g e:yu.t 1a. ,MJiizs trte fOtlowittQ <br /> elr.ptay persons subject lu wur wail's wlunc,L,uliuu laws of Cdtifoll " t � T <br /> I hereby certify that I have prepared this application and that the work will be-done in accordance wiitthh San Joaquin County <br /> ordinances, state laws,and rules an regulations of the San Joaquin Local Health District- <br /> -- <br /> APPLICANT'S SIGNATURE X •- .7- <br /> s <br /> 7- <br /> I. FORDEPARTMEy7 USE ONLY- <br /> Fee IS Dile: ❑ ANNUALLY L1 PER UNIT [I PER SITE. ❑ EACH ❑ January I &Received By January 31 El July 1 &Received By July 31 } <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE :$ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS� t Gj✓ - <br /> PRORATION - <br /> PLUS i <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER <br /> -- r — - _ - -Date Receipt No. Pennil No. I ante D to Mailed Delivered <br /> Received by <br /> 1601 E.HAZELTON AVE.,P.O.go.2009 STOCKTON,CA 95201 <br /> T- ETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> R — <br />