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Applications Will Be Processed When Submitted Properly Completed Bebure Ioalga r11w^Nr••��• <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 nn Joaq infLocoal Health�DI trict fi a kDr�l� <br /> F Business Name (DBA) Q�SC`7 h ?Ark Jilli Address <br /> y � <br /> Address <br /> 7t-eI9C <br /> i Owner <br /> 4 <br /> Firm Partners, Addresses and Telephc lei Numbersill Emergency Telephone No. <br /> aBusiness Telephone No. d[[ <br /> _J Contractor Licence No. g l,llfl ,r <br /> L Applicants Name (Print) 2J Title S1 Date <br /> 1 <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) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July July 1, June 30, 19 <br /> No. of Vehicles Stored V S <br /> No. of Chemical Toilets Stored r.�� <br /> 3. E] PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name E <br /> Test Date/Time <br /> Teovation <br /> t t� <br /> 4.� SANITATION PERMIT rb V �SC L a <br /> Job Address/Location <br /> Owner R OB w1 I t ii v% Address <br /> 13 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 13SEEPAGE PIT 11PACKAGE PLANT t <br /> ❑ OTHER •�O� <br /> ❑ PERMANENT ❑ TEMPORARY El NEW REPAIR a q / "7 jP �N <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Ll <br /> J i <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) 6 <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 a licat' n and that th work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and re <br /> San Jo uin Loc I Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> © ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Ji 31 <br /> Fee IS Due: ANNUALLY REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> } <br /> Received by Data <br /> Receipt No. Permit No Issu a Da Mailed Delivered <br /> t601 E.NAZEL AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />