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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT etj � <br /> LIQUID WASTE <br /> Application is hereby made to carry on�,guslness in the jurisdictional area of the San Joaquin Local Health District <br /> r Business Name (DBA) �to-e"'c "S K % J-11 Lt3�r ' / Address 'Jt Ic tbll 1 f-•c-��.1 C `/ l�V7 <br /> z Owner !`, ' y `t 1-110,14 -77`}he&1' L"59 Y Address 277L1 �� LL ,2�f., - f-PY L LC, <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. _ <br /> L Applicants Name (Print) L�1ivr E r c-;C 7 v% D!`}.'/S Title F-t- 6-f CL 1 l r:T 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 <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 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored -- <br /> 3. ,4 PERCOLATION TEST _ <br /> R.S. or R.C.E. Name )2( ", PFr 7-6 R.S. or R.C.E. No. <br /> Test Location r?Z77nt'/i-e n Test Date/Time �' " { tj;, 'r'+, ' 4-1t,J <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this ap liCa i ;and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rules and regula ons q e Sa 'Joaquin Local Health District. <br /> 7 <br /> APPLICANT'S SIGNATURE X <br /> i <br /> FOR DEPARTMENT USE ONLY <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 E PLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> /� <br /> DATE DATE /REMITTED (AMOUNT <br /> FEE /df,©0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received y Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />