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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> -} APPLICATION <br /> (For Non-Transferable,Revocable,-and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT_',5 ; - <br /> LIQUID WASTEk -* - n • M 1 f <br /> Appl is ion 's h reby made to carry on business in the jurisdictional area oft San oaquln Local Health District r�— <br /> wBusiness Name {DBA} f Address )• 144 1 FW ,. . azo I <br /> F - • - •r �., , t.h <br /> zz Owner Address _ W� <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ,0�a�' �� Emergency Telephone No.i <br /> Contractor Licence Na. <br /> Applicants Name {Printf' Title ��`9 Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information,.d3 a - w,,• ,_, 't, .3�, ;_j w ..� . , <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 -Disposal Siies - - - - <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL" Licensi Renewal No. <br /> Capacity Gal.,.Weights & Measures No. <br /> t i <br /> Equipment Parking Address <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 <br /> I R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test�Locion Test Date/Time ` <br /> 4. I SANITATION PER # # <br /> Job Address Location �G> <br /> Ow f% m � +�,—�,� Address - /� afl <br /> t J SEPTIC TANK? ❑ CESSPOOL' LEACHING FIELD If SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ERMANENT ❑ TEMPORARY ❑ NEW ®REPAIR ❑ OTHER 4 <br /> 5. ❑ 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 r V Where Certified 1 <br /> Plant Location ' ` 0 <br /> ,. <br /> Plant Capacity � O <br /> No. Units Served �� <br /> 7. ❑ LAUNDRY ;For July 1, -`June 30, 19 <br /> SIZE: Less Than 1,004 Sq. FL, ., 0, More Than 1,000 Sq. Ft ; <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMo.-. <br /> ial hereby certify that I have'prepared.•fhi9-applicati and the the work will be done in accordance with San Joaquin County <br /> ordinances, state laws d ule _and r lations e S J aquin ocal Health District, <br /> APPLICANT'S SIGNATURE I <br /> S. <br /> FOR DEPARTMENT USE ONLY. <br /> t t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER-UNIT' C1PER SITE 13EACH 11 January 1 &Received By January 31 EI July 1 &Received By July 31 <br /> z ... REMIT <br /> BILLING REMITTANCE $ <br /> BASE' EXPLANATION AMOUNT RUE. CHECKED <br /> t - DATE DATE REMITTED AMOUNT <br /> FEE. I }Y fJ <br /> LESS f . '• i. �'� ' .y <br /> h PRORATION ` <br /> PLUS <br /> PENALTY <br /> a g. OTHER <br /> OTHER <br />[r a, Received by Date Receipt No. Permit No. - Iss anteate ~ ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O. 009 STOCKTON,GA 95201 <br /> . J_ <br />