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Applications Will Be Prom ,When Submitted Properly Completed.Be Sure gn The Application. <br /> APPLICATION , <br /> (For Non-Transferable,Revocable,-and Suspendable)_ SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> A licationIS reb made car ts <br /> on In then rlsdictional area of theInj�,n�oa Local ealt trict <br /> a Business Name(DBA) Address s•G3L Q �� <br /> Owner Address— - - - - <br /> Firm Partners,Addresses and Telepho a Numbers <br /> IL <br /> Business Telephone No. -VZEmergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date <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 R.S.or R.C.E.No. <br /> Teocation Test Date/Time <br /> 4. �SANITATION PERMIT- <br /> Job Address/ oc tion c <br /> Owner EV96 7�TrT- Address-, z °p <br /> ❑ SEPTIC TANK ❑ <br /> CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT �Q <br /> ❑ PERMANENT` ❑ TEMPORARY • ❑ NEW REPAIR J40THER PAM/4l JXE.P �1 <br /> S. ❑ CHEMICAL TOILkTS F,or+July 1,-June 30, 19 <br /> Type Construction t Disposal Site <br /> j--- <br /> No.of Units ' ' Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE,TREATMENT.PLANT. For July 1,-Juni<16"19 i <br /> Operator Name '`+ - ) I t - Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served 1 ` <br /> 7. 1:1 LAUNDRY For July 1,=June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1',000 Sq, Ft. - , !� <br /> ❑ DRY CLEANIfNG,Chemicals Osed/Amount/O. n <br /> f h6reb' <br /> y certitj tthat,l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> brdintirfic�s-s�t t1? <br /> la*i,and rule dregulation of the S quln L c Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY ' <br /> Fee Is Due: ❑ ANNUALLY ❑ PFR UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1&Received By July 31 i <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE E AMOUNT DUE CHECKED <br /> .� DATE -DATE REMIT] 1 <br /> AMOUNT <br /> FEE ` -kinr ! t 11 1 0' .� <br /> LESS <br /> PRORATION <br /> PEN LTY <br /> OTHER <br /> OTHER <br /> - - o <br /> Received by Date Receipt No. Permit No. Issuance Date ail Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAiELTON AYE.,P.O. .2009 •STOCKTON,CA 95201 <br />