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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appucaricn. <br />APPLICATION / <br />(For Non -Transferable, Revocable, and Suspendable) SEPTAGE <br />., __ ...... _._ <br />BILLING <br />EXPLANATION DA(E <br />ENVIRONMENTAL HEALTH PERMIT <br />AMOUNT DUE <br />LIQUID WASTE <br />Application is hereby de carly. on business in the jurisdictional area of the San Joaquin Local Health District <br />-........... . <br />(n e3usiness Name. (DBA) �`' - Address . <br />- <br />i Owner ___ -.- ,Address <br />--- <br />Firm Partners, Addresses and Telephone Numbers <br />u <br />a.—.Emergency Telephone No.— - <br />a Business Telephone No. _ <br />a �� % <br />Contractor Licence No. _ a . ;. •:. <br />N <br />Applicants Name (Print) ,� �1 -Tele �„ ! ,;, -Date <br />Please check Applicable Category (1-7) and Fill in the Required Information' <br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />PLUS <br />For July 1, June 30, 19 _ _,. -: , Disposal Sites <br />Description (Make/Yr., Color) <br />Serial No. - v , CAL. License No. _ _ _ CAL. License Renewal No. ...... <br />_ <br />Ca acit .� Gal., Weights & Measures No. <br />Y <br />P — <br />Equipment Parking Address - <br />- - — <br />2. ❑ PUMPER YARD ♦ , <br />OTHER--- <br />--- ' <br />For July 1____ June 30. 19 - <br />No. of Vehicles Stored <br />No. of Chemical Toilets Stored - - <br />3. ❑ PERCOLATION TEST s <br />R.S. or R.C.E_ No. <br />A.S. or R.C.E. Name _ _ z <br />Test Location Test Date/Time -- <br />11 3 <br />-- <br />4. SANITATION PERMIT <br />Lc d 7 Q� > 6 06- � <br />Job Address/ Location -- r L- -- —" <br />Owner_!v.-Address _ �_l°—.ani--��' <br />•--_ <br />92'/SEPTIC TANK ❑ CESSPOOL 98- EACHING FIELD ❑ SEEPAGE PIT',, ❑ PACKAGE PLANT <br />❑ PERMANENT' ❑ TEMPORARY ❑' NEW ❑ REPAIR '-' 0 OTHER <br />.5. ❑ CHEMICAL -TOILETS . For July_ 1, - June 30, 19 <br />Type Construction Disposal Site.,_ <br />- <br />No. of Units -_ T. — Equipment Std age/Cleaning Location(s) <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />- - Where Certified - <br />Operator - <br />Name <br />Plant Location - - <br />No. Units Served <br />Plant Capacity - <br />7. ❑ LAUNDRY For July 1, - June 30, 19 \4 <br />SIZE. ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br />hereby certify that I have prepared this application and'that the work will be done in accordance with San,Jdaquin County <br />ordinances,.state laws, ari+j rules andlat" ns of Ihe San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X <br />a <br />~�CA, <br />J� <br />� <br />3 r -. <br />' ' <br />S � <br />x <br />+. FOR DEPARTMENT USE -ONLY <br />ice Receivetl.8v Jan ud'Y 31 <br />a � <br />❑ Jwy 1 A Received By'Juiy 11 <br />rev 13 UUC, L Hrvry +amuu ,...,,_. <br />._..__._ <br />' <br />©ASE <br />., __ ...... _._ <br />BILLING <br />EXPLANATION DA(E <br />-__ <br />REMITTANGE =•t L ,--5 .-� <br />"DATE:- REMITTED <br />AMOUNT DUE <br />REMIT' <br />CHECKED% <br />AMOUNT N- <br />-........... . <br />FEE. <br />. <br />LESS Z <br />PRORATION <br />PLUS <br />PENALTY _ _ <br />-- -- <br />- - — <br />-- <br />OTHER--- <br />--- ' <br />t <br />OTHER <br />Recervea by Date Receipt No. enn+t NoSSU <br />tce Mated Delivered <br />APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -• 1801 E. HAZELTOaP.O. Box 2009 STOCKTON, CA 95201 — <br />4 <br />t _ <br />