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ApplicationsWill Be ProcessedWhen Submitted Properly Completed. Be SureTo SignTheApplication. <br /> "APP61CATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati n reby made tdca on busin ss in the jurisdictional area oft an J yiP IH Di i t �5 � j <br /> wBusiness Name (DBA) t� Address '- � <br /> i Owner Address _ <br /> a <br /> J Firm Partners, Addresses and leppone-bLurnbers <br /> o. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) Title 2-- nn!V Date 10 <br /> Please check Applicable Category(1-7) and FI 11 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 r_ <br /> No. of Chemical Toilets Stored, <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Namey R.S.or R.C.E. No. <br /> Test Location _ ~` -µTest Date/Time <br /> 4.XSANITATION PERMIT <br /> Job Addres cion <br /> Owner Ile6TIA Address— <br /> XSEPTIC TANK ❑ CESSPOOL XLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT /} <br /> J@ PERMANENT ❑ TEMPORARY ❑ NEW _.i +XREPAIR .OTHERr&'�jv� <br /> 5. 11 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 �+ T <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. r <br /> K + f <br /> I hereby certify that I have prepared this ap do and that the work will be{ddne'irl accordance with`San Joaquin County ' <br /> ordinances, state laws, and rul r to of h San J quin Local Health District- - <br /> APPLECANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION BILLING DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS ` <br /> PRORATION <br /> F <br /> E a i <br /> it <br /> PLUS I + ._ r-• ' ?� 4 <br /> PENALTY � j <br /> OTHER E y <br /> OTHER <br /> Received by Date € Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 , <br />