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Applications WIII Be Processed When Submitted Property Completed. Be SurTo Sign The ApplicationA/A / <br /> 'APPLICATION Z L <br /> Non-Transferable,Revocable,and Suspendeb SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> LIQUID WASTE <br /> Ap'plicalionisherob made to car on sinass in the jurisdictional area of the San Joaquin Local Health D's 'Ct <br /> Business Name (DBA) / ��' Address <br /> `z Owner �- •Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Piint) Title .�,rrt/BK. Date - <br /> Please check Applicable Category(1-7i and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 'JI <br /> For July 1, June 30, 19 "Disposal Sites C' <br /> Description(Make/Yr..Color) - <br /> Serial No. CAL. License No. CAS.. License Renewal No. <br /> Capacity Gal.,Weights&Measures No. ! - <br /> 9' <br /> Equipment Parking Address . <br /> 2. ❑ PUMPER YARD I �. <br /> For July 1• June 30, 19 tu <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets StoredI <br /> 3. ❑ PERCOLATION TEST <br /> R.S. Or R.C.E. Name R.S. or R.C.E. NO. "y <br /> Test Location _ Test Dale/Time <br /> 0. ❑ SANITATION PERMIT ` <br /> Job Address/Location <br /> Qwn , _D'- 5 Address ,�� y' l <br /> - 11 <br /> SEPTIC TANK ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLA <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. Q CHEMICAL TOILETS For July 1,-June 30,19 -� <br /> Type Construction / Disposal Site O <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. PACKAGE TREATMENT PLANT-o'July T.--7un8-30'19T_ -"' - - - •- -- -' ----+ <br /> Operator Name _ 3 - Where Certified <br /> Plant Location �,rt•_ _ _ _ ____ _ - ------ - <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30,18 T _S,; `I <br /> SIZE: El Less Than 1,000 Sq. Ft., "❑'MorbNThad 1,000.Sq.Pt. =v S k <br /> ❑ DRY CLEANING,Chemicals Used/AmounVM0. • '` .' - <br /> I hereby certify that;I have Prepared this application and thdf the work will be Cone iry.1acoorda0ce with San Qpaquin County <br /> ordinances, state laws,and rules andregula ' sof,1a San roaquin Local Health District. _ <br /> APPLICANT'S SIGNATURE ' <br /> F�R OEPARt RENT t1SE ONLY ; <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE „ ❑ EACH ❑ January 1 &Received B 'January 31 ❑ July 1 &Received By July 31 <br /> - - - REMIT <br /> it BASE EXPLANATION BILLING REMITTANCE - S AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY._. <br /> OTHER <br /> OTHER . <br /> a$��1 i las lB l <br /> Received by Date Ret¢ipl NO. PCrmn No I uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Be.2009 STOCKTON.CA 95201 <br />