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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 <br /> - LIQUID-WASTE <br /> Applica,to is hereb ma4e t rry on busine in the jurisdictional area of th an Jo uin Local e I -District Q r <br /> NBusiness Name (DBA) m Address VFIN <br /> W <br /> �. <br /> z Owner - - - Address <br /> J Firm Partners, Addresses and Te W hone Numbers 4 <br /> 1L-d <br /> No. f _ Emergency Telephone No, <br /> ' a Contractor Licence No. _ <br /> L Applicants Name (Print) ,Title Y Date <br /> Please check Applicable Category (1-4)and,Fill in the Required Information. <br /> ' 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ` <br /> r r for July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) r <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> i Capacity Gal., Weights &Measures No. <br /> I Equipment Parking Address <br /> 2 © PUMPER YARD._._... ,�.,, _. ._ _-. ..� :.,.a, - � ..r. •�a....».,..� .r .� _ �......_._,..�.. . <br /> r <br /> For July 1, June 30, 19 <br /> i No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST E-�.� � --• <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. ' <br /> Test Location t Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location <br /> f Owner Ad ress <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING-FIELD ❑.SEEPAGE PIT ❑ PACKAGE PLANT + <br /> PERMANENT TEMPORARY ❑-NEWS �� �a� REPAIR �gjOT <br /> �I ❑ HER Io <br /> 5. ❑ CHEMICAL TOILETS For July 1,=June 30, 1.9 <br /> Type Construction —Disposal <br /> No. of Units t Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t <br /> Operator Name Where Certified===v -- <br /> Plant Location <br /> Plant Capacity f No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -#June 30,19— <br /> SIZE: <br /> 0, 19.-SIZE: 0 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. +' <br /> R <br /> hereby certify that 1 have prepared this applic ion and that the work will be done,in accordance`+nrith San Joaquin C unty <br /> ordinances, state laws, and rules and r atio of San Joaquin Local Health Districf.' <br /> . . ,. -s <br /> T <br /> PP <br /> ALICAN 'S SIGNATURE X W 7 <br /> � . . - _- . - _ - - � - � � . ' . . r��.... . � •ate <br /> FOR DEPARTMENT USEyONL:P' 4. 6 <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31� ❑ July 1 8 Received By July 31 <br /> - - r REMIT <br /> 4 i BASE EXPLANATION BILLING REMITTANCE �$ MOUNT DUE CHECKED <br /> t_-DATE..,,.........,.DATE I-..... ..�REMITTED.--.,...m - ' <br /> AMOUNT <br /> r FEES f.... T <br /> LESS <br /> "PRORATION <br /> PLUS t <br /> PENALTY -- - Of <br /> OTHER <br /> 3' <br /> a..OTHER <br /> r' - > 'Petrol[No_" I nq Mailed Delivered <br /> Received by r Date Receipt Y o: r r <br /> ' <br /> APPLICANT RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES' "' 1601 E.HAZELTON AVE.,P.D.Bpx 2009 STOCKTON,CA 95201 - <br />