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Applications Will Be Processed When Submitted Properly Completed. Be Sure o Sign The Application.�`� �/ f <br /> APPLICATION <br /> - Non-Transferable,Revocable,and'Suspendabl / SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to car on business in the Jurisdictional area of the San Jg81r1uin Local Health Distf,,ict <br /> a Business Name (DBA) _�..TSL L Address .� / /�3a,/ D fiV/TG 1L <br /> i Owner,44416 F4LL tr �, Address _ <br /> Firm Partners, Addresses and Tejephone�Numbers �. <br /> i Business Telephone No. �rr�1 'Emergeb Telephone No. <br /> Contractor Licence No. 11751b. <br /> Applicants Name (Print) ,Title Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTR(1TION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Dtsposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address ??? <br /> 2. ❑ PUMPER YARD. Ft '• -� <br /> For July 1, June 30, 19 r <br /> No.of Vehicles Storedt If - <br /> No.of Chemical Toilets Stored I• _ <br /> 3. ❑ PERCOLATIONTEST <br /> R.S. or R.C.E.Name R.S.Or R.C.E. No. <br /> Test Location - Test Date/Time <br /> 4. ❑ SANITATION PERMIT `` 1 <br /> Job Address/Location r LLTl ��a _ 't••a <br /> O,wr Address' S- <br /> W SEPTIC TANK ❑ CESSPOOL PLEACHlNG FIELD ❑ SEEPAPE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,.19 - <br /> Type Construction Disposal Site L <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 W <br /> Operator Name Where Certified <br /> Plant Location I <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 0 Moie'Than 1,000_$q. Ft. •t'� 11 <br /> ❑ ORY CLEANING,Chemicals Used/Amount/Mo. <br /> ,t <br /> I hereby certify that I have prepared this a plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,and rules and reg ion;o he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X (. '' 7 -p vaS1 � �r'• r I ' <br /> �% <br /> i / F — FOR DEPARTMENT USE ONLY <br /> Fee 1s Due: ❑ ANNUALLY ❑ PERNNIT ❑ PER SITE 13EACH ❑ January 1 d Received By January 31 ❑ Juty 1 A Received By July 31 <br /> 1 ` S., r ,iREMIT <br /> SASE 'I r EXPLANATION '• BILLING • REMITTANL� 1 (' AMOUNT ) , CHECKED <br /> 1 <br /> i DATE .t _. DATE,. REMITTED "AMOUNT <br /> FEE i , __ —•_ _V. ��_ — ., j <br /> LESS <br /> PRORATION <br /> PLUS - / I <br /> PENALTY I , <br /> OTHER �• 't; <br /> .. OTHER <br /> Rec¢ned by Date Receipt No. Permit No imuzince DateMailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16111 E.HAZELTON AVE.,P.O.aoa 2009 STOCKTON.CA 95291- <br />