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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />r <br />For Non-Transferable, Revocable,'and Suspendable) SEPTAGE <br />ENVIRONMENTAL HEALTH-PERMIT <br />LIQUID'WASTE <br />w' Appl ication is hereby made to carry on busine4 in the jurisdictional area of ttje San Joaquinoca ealth District <br />V r Business Name (DBA) <br />AddressLI V fl <br />z Owner I 1Y Address <br />L) Firm Partners, Addresses and Telephone Numbers <br />a. Business Telephone No. g Emergency Telephone No. <br />Contractor Licence-No. . <br />a s"I.. . . Title Date <br />L Applicants Narrie {Print) <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, <br />Y <br />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- 4---&-_..y-- <br />Equipment Parking Address <br />2. PUMPER YARD <br />For July 1,—, June 30, 19 <br />No. of Vehicles Stored <br />u_ <br />No. of Chemical Toilets Stored <br />3. PERCOLATION TEST t <br />R.S.or R.C.E. Name R.S. or R.C.E. No. <br />Test Location Test Date/Time <br />4. 0 SANITATION PERMIT <br />r Job Address/Loc; t'o[I <br />Owner_ "t l 1 s Address <br />F s <br />@,e EPTICTANK CESSPOOL LEACHING FIELD SEEPAGE PIT 0 PACKAGEPLANT ( + "t <br />PERMANENT ') TEMPORARY i NEW REPAIR OTHER <br />5.jO CHEMICAL TOILETS ForsJul 1,-June 30, 19 <br />fTypeConstruction <br />y <br />Disposal Site <br />r <br />No.of Units Equipment Storage/Cieaning'Location(s) <br />6- PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br />Operator Name--- Where`Certified <br />Plant Location <br />Plant Capacity No. Units Served, .. <br />M` <br />7. 11 LAUNDRY For July 1, -June 30, 19 <br />SIZE: El Less Than 1,000 Sq. Ft., 0 More Than 1,000Sq. Ft. f4,;-1 A <br />f,' <br />DRY CLEANING, Chemicals Used/Amount/Mo. P., ' " ' ' <br />r <br />A4 r r y <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />7__ordinances,. to d rules a regu tions o he Sa Joaquin Local Health"District. <br />APPLICANT'S SIGNATU <br />1 <br />FOR DEPARTMENT USE ONLY k ` i <br />l <br />Fee Is Due: ANNUALLY PER UNIT PER SITE EACH January 1 &Received By January 31 ; July 1 &Received By July 31 ' <br />REMIT <br />BILLING REMITTANCE AMOUNT DUE CHECKED 1 <br />BASE EXPLANATION <br />DATE DATE REMITTED <br />j <br />AMOUNT <br />FEE , T <br />OC7 <br />1I <br />LESS <br />PRORATION: <br />PLUS <br />PENALTY <br />4 OTHER <br />OTHER <br />Received by _. Date Receipt No Permit No. Iss ante to Mailed Delivered <br />t <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITY$ERVICES "'' -'16D1 E.-HAZELT E.,P.O.Box 2009 STOCKTON,CA 95201