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Applications Will 19e Processed When Submitted Properly <br />APPLICATION Q <br />y Far Non-Transferable,Revocable, and Suspendable) SEPTAGE r <br />ENVIRONMENTAL HEALTH PERMIT q # <br />LIQUID WASTE <br />Application is er y made to carry o business in the jurisdictional area of the San Joaquin Local Health District <br />G <br />1 Address r <br />N Business Name (DBA) o <br />y Address <br />a Owner I <br />ll lll'J Firm Partners, Addresses and Telephone Number llr ..............Emergency Telephone No. <br />0. Business Telephone No. <br />J Contractor Licence No. i Title A/Date <br />Applicants Name (Print) <br />Please check Applicable Category (1-7) and Fill in the Required Intormation <br />1. PUMPER VEHICLE PERMIT REGISTRATION (F ORo <br />aACSH <br />VEHICLE) <br />For July 1, June 30, 19 <br />Description(Make/Yr.,Color)CAL. Licc-se Renewal No. q <br />Serial No. <br />CAL. License No.i <br />Gal.,Weights &Measures No. <br />Capacity <br />Equipment Parking Address <br />a_ 1 <br />2. PUMPER YARD <br />For July 1, June 30, 19 <br />No, of Vehicles Stored <br />No. of Chemical Toilets Stored <br />3_ PERCOLATION TEST R.S.Or_R.C.E.No. ti <br />R.S. or R.C.E. Name Test Date/Time <br />Test Location <br />4. SANITATION PERMIT <br />J <br />Job Address/Location <br />077l <br />Address <br />4 <br />Owner <br />LEACHING FIELD SF PAGE".PITT , <br />PACKAGEPLANT <br />SEPTIC TANK CESSPOOL OTHER <br />f. <br />C1 PERMANENT ., - <br />TEMPORARY.,NEW E PAIR <br />I 5. C3CHEMICAL TOILETS For July 1;- June 30, 19 <br />Type Construction <br />Disposal Site <br />l Equipment Storage/Cleaning Location(s) <br />k <br />No. of Units fi <br />f 6. PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br />Where Certified <br />Operator Name <br />k Plant Location No. Units Served <br />Plant Capacity f <br />7. 11 LAUNDRY For July 1, -June 30, 19 ki i <br />More Than 1,000 Sq. Ft. <br />SIZE: Less Than 1,000 Sq. Ft., r ' 4 <br />DRY CLEANING, Chemicals Used/Amount/MO. f R Lam. <br />r <br />i <br />I hereby certify that I havefppared thisapplication and that,the work will done.-in accordance with San Joaqui County <br />ordinances, state laws, and rules and re lations of the San Joaquin Local HealtY District. s ` <br />APPLICANT'S SIGNATURE X f <br />tFOR DEPARTMENT USE-ONLY <br />nue <br />31 <br />REMIT <br />Fee IS DUB: ANNUALLY ' P,ER;UNIT <br />1 - <br />El PER SITE <br />T <br />EA H" 'January 1 &Received By January 31 July t 8 Receive y July <br />4 T REMITTANCE AMOUNT DUE CHECKED <br />BASE ~ <br />BILLING <br />DATE REMITTED AMOUNT <br />I <br />4 r <br />FEE - t <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />t <br />Issuance Date Mailed Delivered <br />Permit No. <br />Date Receipt No. <br />Received by 1501 E.HAZELTON AVE.,P.O.Box 2009 5TOCKTON,CA 95241 <br />APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH-PERMIT/SSERVICES ,. n. „x—