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NPONOW 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 /> ,Business Name (DBA) Address <br /> a Owner C/V�i) 1 /'f1�fDF/L 77F Address -' /aC ICUZ 9 — 5>7ZT 1L Z). e"A <br /> Firm Partners, Addresses and Telephone Numbers /�1-i� <br /> a. Business Telephone No. Emergency Telephone No. L — ✓i�� ' �' <br /> Contractor Licence No. _ <br /> Applicants Name (Print) -S Vt l.�f�J/S ir.lr� �>>�C tie -i`' Date —r <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. &PERCOLATION TEST _ <br /> R.S. or R.C.E. Name /7 ' Ale rt"r-� R.S. or R.C.E. No. Z_c Z j 5 <br /> Test Location '!e''' i 1=G75 Srly;J — ,'c ✓i llt)oate/Time /lam ��/7tE i� �Lr.°� .•. pS�`i7�/� i :,T?� <br /> 4. ❑ SANITATION PERMIT L- T—.S <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 application and that the work will be done in accordance with San Joaquin Cou ty <br /> ordinances, state laws, and &pIes and reg ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 B Receivec By July 31 <br /> R MIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CH CKED <br /> DATE DATE REMITTED ANDUNT <br /> FEE O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 <br /> Received by D to Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON, A 95201 <br />