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Applications Will Be Processed When Submitted Properly Completed. BeSureTo sign <br /> r <br /> I� APPLICATION <br /> II (For Non-Transferable,"-Revocable,and Suspendabte) SEPTAGE <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> u LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San,-Jo quinLocal Health District <br /> y Business Name (DBA))]. � } �� — ��}C'. Address V <br /> IV., !. t <br /> z Owner Address. <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> J [� � Ln p Emergency Telephone No. - f <br /> a Business Telephone No. + <br /> Contractor Licence No. - _ <br /> Title -� Date. <br /> Applicants Name (Print) <br /> Please check Applicable Category:(1- }. <br /> 7 and Fill in the Required Information <br /> , <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE} <br /> - <br /> For July 1, June-30, 19L -- Disposal.Sites _. <br /> Description(MakeNr., Color) CAL. License Renewal No. <br /> Serial No. !' CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. I] PUMPER YARDo <br /> For July 1, June 30, 19'M ` <br /> No.of Vehicles Stored ° <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> 3 R.5.or R.C.E.No. F <br /> R.S. or R.C,E, Name _ <br /> Test Location Test Date/Time <br /> .4. ❑}SANITATION PERMIT <br /> Job Address/Location <br /> Owner 1�?11 1J L.i• f Address <br /> � - <br /> k ❑ LEACHING F11IELD SEEPAGE PIT 1 ❑ PACKAGE PLANT <br /> EPTIC TANK C3 CESS + <br /> ❑.SPOOL: ( REPAIR t <br /> ❑•PERMANENT ❑ TEMPORARY ❑ NEW t �..iE <br /> 5. ❑ CHEMICAL TOILETS For Jul 1,-June 30, 19 [ I <br /> A. y Disposal Site � � <br /> Type Construction p > x� - I o <br /> No. of Units - '- Equipment Storage/Cleaning Locations) .� <br /> 6.',[]y ..PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> 3 <br /> Where Certified <br /> Operator Name u It IV i ► n q <br /> Plant Location , 4 ,. <br /> ! No. Units Served t <br /> Plant Capacity " d e I <br /> 7. ❑ LAUNDRY For July 1, s June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. [ <br /> y. A <br /> ❑ DRY CLEANING, Chemical s..Used/Amount/Mo. - <br /> Ar I <br /> +" <br /> } <br /> hereby certify that I ha prepared-this application and that the work"will be done'in ccordance with San Joaquin County <br /> ordinances, state laws, n _rules and r ulations of" h San Jo quinkocal Health f7istrTcly <br /> APPLICANT'S SIGNATURE X. # - 6 <br /> ' i l �� I• I 4 <br /> 0 FOR DEPARTMENT USE ONLY- <br /> ❑ PER SITE ❑ EACH, ❑ January 1 &Received By January 31,..... 0 July-l-&Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY, _❑ PER UNIT _ REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> I� - <br /> FEE r <br /> f T � <br /> LESS F -- - .. <br /> PRORATION <br /> PLUS I� 41— <br /> PENALTY <br /> OTHEflIh -.•�. ' <br /> OTHER - <br /> II41 <br /> Received by Date Receipt No. Permit No, s uanc Date ailed Delivered, <br /> _ 1601 E.HAZELTON AVE. P.O. ox 2009 STOCKTON,CA 95201" <br /> APPLICANT -RETURN ALL�COPIES TOi ENVIRONMENTAL HEALTH PERM <br /> ? I] <br /> ! II <br />