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r <br /> 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 <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) Address <br /> z Owner I ` '�:i ___ Y� `J Address 7 �`=•I-=' 41 �(Vf� �rAN i��;� :.+� J <br /> _ <br /> Firm Partners, Addresses and Telephone Numbers / <br /> J <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. _ <br /> Applicants Name (Print) WAt_;E i� .t C_ --' .`1 1 Title -t'`tL �= `►'-r "�- Date <br /> 39 <br /> Please check Applicable Category (1-7)and Fill in the Required Information P_ - <br /> , <br /> 1. E] PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEH �t ' �' ��, �`��� =�� �- 1 c1 <br /> For July 1, June 30, 19 Disposal Sites ^' <br /> Description(Make/Yr., Color) `r <br /> Serial No. CAL. License No. CAL. License Renewal No. - t <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD `1.a <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> YVf `.VEi. E ^I_' R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name GU�i <br /> Test Location ';�1 int E_,I ,.- y r' Test Dat /Tim@_ 7\t I` `1_F- '`r `) <br /> I r_ 1�r t `�STI:�i ;:;\'r c �T lel <br /> 4. 11 SANITATION PERMIT * ,,1i�_ - t.�M-e=_ - r t': �,J.�h l - f - <br /> Job Address/Location A Ln n I�' -^)L <br /> PL2dFr L� HOl_� <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEWr-A%Wlliz,,PAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction_ Disposal Site <br /> No. of" Equipment Storage/Cleaning In <br /> ex- - Now <br /> 6. ❑ PGE 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 /> ❑ DIY CLEANING, Chemicals Used/Amount/Mo. <br /> i <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 the San Joaquin Local Health District. <br /> �.- T-- <br /> APPLICANT'S SIGNATURE Xy; <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE p <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Y ' <br /> Date �TReceip)N0 4 Permtt Igo.- Issuance Date Mailed Delivered <br /> fib...: •. ,,,} <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONME�11xALF1E71L'�'i'tPLYH�RPf/SEWVIC�9 ' 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />