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Application's Will Be Processed When Submitted Properly Completed. Be_ Sure To Sign The Application. <br />APPLICATION <br />For Non-Transferable, Revocable, and Suspendable)f( SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT I <br />LIQUID WASTE <br />i Appl icati n is hereby made tQ c_ar on busin in the' rl dlctional area of the S_ Joaquin Local Health District t <br />m Business Name {DBA}Address G .L r ` , ca <br />a Owner LE F. L Address <br />J,Firm Partners, Addresses a el i hone Numb rs __ <br />a. Business Telephone No. Emergency Telephone No. <br />Contractor L'icence•No. <br />Apiplicants Name(Prt) C C Title -- Date <br />Please check Applicable Categoryk(1-7) and Fill in the Required Information <br />z , x L <br />1. - PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July 1, June 30, 19- Disposal Sites- 1 <br />Description(Make/Yr., Color) q <br />Serial No. I CAL. License No.CAL License Renewal No. <br />CapacityGal.-Weights'&"Measures-NO.— <br />Equipment <br />NO.— <br />E ui ment Parking Address TI <br />2. PUMPER YARD <br />For July <br />No. of Vehicles Stored <br />No. of Chemical Toilets Stored <br />3. PERCOLATION TEST <br />R.S. or R.C.E. Name N R.S. or R.C.E. No. <br />Test Location Test Date/Time <br />4. SANITATION PERMIT <br />Job Address7Loc2tionct <br />Owner U ` Z Z)i R -N E i T Address <br />SEPTIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT PACKAGE PLANT = <br />PERMANENT TEMPOR"ARY NEW REPAIR OTHER <br />5. CHEMICAL TOILETS For'July 1, -June 30, 19 r '"'- <br />T <br />Type Construction 4 Disposal Site TNo, of Units M Equipment Storage/Cleaning Location(s) i ! <br />6. PACKAGE TREATMENT PLANT For July 1, -June 30, 19 f ' <br />Operator Name Where Certified--- t1 <br />Plant Location r <br />Plarit Capacity <br />Y <br />No. Units Served. r <br />i <br />7. , LAUNDRY For'July 1, -June 30, 19- a { <br />SIZE: . 'Less Than 1,000 Sq: Ft., More Than 1,000 Sq. Ft. <br />DRY CLEANING, Chemicals Used/Amount/Mo. <br />I hereby certify7tht have prepared this application and at the work will be done in accordance with San Joaquin County <br />ordinances, sta lavys, a d ri tes an regulatAns the S J.oa in Local Health District. <br />APPLICANT'S SIGNATURE X <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: 11ANNUALLY ,I PER UNIT PER SITE EACH January 1 &Fleceived By January 31 July 1 &Received By July'31 <br />c <br />w 1 <br />REMIT r <br />BASE I EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKEp' <br />r' <br />s DATE ATE t REMITTED AMOUNT <br />FEE <br />t i <br />3 LESS <br />PRORATION <br />PLUS <br />PENALTY L I <br />S <br />OTHER <br />I OTHER .>Ili V <br />AAF <br />x <br />Received by _ Date Receipt No 'k Permit No.Issuance Date ailed Delivered. - <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201