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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 /> ) 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 L <br /> 5. 13 CHEMICAL TOILETS For July 1,-June 30, 19 01 <br /> ► J FType Construction _ Disposal Site f <br /> No.of Units Equipment Storage/Cleaning Location(s).' � 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 /> f7. ❑ 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 l� ordarlce 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 009 <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J ry 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> f REMIT <br /> BASE EXPLANATION BILLING RE ITT CE f AMOUNT DUE CHECKED <br /> DATE AT REMITTED AMOUNT <br /> FEE J~ <br /> LESS <br /> PRORATION - <br /> FLUS <br /> PENALTY <br /> L <br /> OTHER <br /> - OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date CoValled Delivered <br /> k' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 E.HAZELTON AVE,P.D.Bos 2000 STOCKTON.CA 95201 , <br /> r <br />