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tj Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />7, APPLICATION i <br />(For Non -Transferable, Revocable, and Suspendable) SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Application i heret ylmade o carry on business in the jurisdi tional area of the San oaquin Local Health Distri <br />Business Name (DBA Address <br />z Owner_ Address <br />4 <br />9 Firm Partners, Addresses and Telephone Number - <br />aBusiness Telephone No. - Emergency Telephone No. _ <br />Contractor Licence No. <br />Applicants Name (Print) —Title Date <br />_ E <.. _, ., .,.... a <br />k{6 Please check Applicable Category (1-7) and Fill in the Required Information <br />1:"'PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)( i <br />J For July 14='June 30; 19 Disposal Sites t <br />F —+� <br />Description (Make/Yr., Color) <br />I Serial No. CAL. License No. CAL. License Renewal No. <br />Capacity _ - Gal., Weights & Measures No. id I <br />Equipment Parking Address - -- - <br />2. ❑ PUMPER YARD <br />1 For July 1, June 30, 19 _ �---- -�-- <br />No. of Vehicles Stored <br />No. of Chemical Toilets Stored - q <br />3. ❑ PERCOLATION TEST {y1� <br />R.S. or R.C.E. Name R.S. or R.C.E. No. <br />Test L eation e.stD <br />ate/Time F <br />4. 3 SANITATION PERMIT ) <br />Job Address/Location ,7- 4 <br />Owr —� 3 Address - _s <br />f 1,9, SFEPTIC TANK ❑ C SPOOL 13 <br />L�HING FIELD 5� i ❑ PACKAGE PLANT <br />j LWPERMANENT El TEMPORARY L3'NEW �V ❑ REPA R i -1 OTHER t <br />y { g <br />5. 13 CHEMICAL TOILETS For July 1, -June 30, 19 ► J Type Construction _ Disposal Site _ <br />No. of Units Equipment Storage/Cleaning Location(s).'� i 1 <br />t 1 <br />5. Cl PACKAGE TREATMENT PLANT For July 1, -June 30; 19--�----�--�; �I <br />Operator Name l� Where Certified <br />Plant Location <br />Plant Capacity INo. Units Served <br />l 7. ❑ LAUNDRY For July 1, - June 30, 19 <br />SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Fe,� v� a <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br />I hereby certify that I have prepared this application and that the work will be done ll� ordarice with San Joaquin County <br />i ordinances, state laws, and rules regulations oft an Joaquin Local Health Distric . <br />APPLICANT'S SIGNATURE X - �--- , <br />FOR DEPARTMENT U O <br />n n i x na—i—i By January 31 ❑ July 1 & Received By July 31 <br />Fee Is Due: U ANNUALLY <br />u rcn <br />BASE <br />vw, <br />EXPLANATION <br />_ — - - <br />BILLING <br />DATE <br />RE ITT CE <br />AT <br />f <br />REMITTED <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION <br />J~ <br />- <br />PLUS <br />` <br />PENALTY <br />L <br />OTHER <br />OTHER <br />C/a <br />I` Received by Date Receipt No. Permit No. <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />RI <br />1661 E. HAZELTON AVE, P.D. Bos 2009 5TOCKTON. CA 95201 <br />I <br />/�_a <br />