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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applications T <br /> APPLICATION <br /> oNon-Transferable,Revocable,and Suspendeb SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application Is he b'y ade to carry on business in the jurisdictional area of the Sart.loaquin Local Health District <br /> F �L CGC Address I//o <br /> m Business Name (DBA) - r <br /> Owner Address <br /> Firm Partners. Addresses and Telephone Numberssf. <br /> o Business Telephone No. a5 y.S ; Emergency Telephone No. <br /> a 7 ^ <br /> � Contractor Licence NO. <br /> Applicants Name (Pring 7 «-rK Title Date—� <br /> Please check Applicable Category (1-7) and Fill In the Required Information - 41 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION-(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 _ Disposal Sites <br /> Description(Make/Yr.,Color) ' <br /> Serial No. _ CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights A Measlires'No. <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 — <br /> No. <br /> 0, 19 ^_No. of Vehicles Stored .. , <br /> NO. of Chemical Toilets Stored <br /> 3. Q PERCOLATION TEST <br /> R.S.�or R.C.E. Name R.S. or R.C.E. NO. <br /> Test Location _ _ -/fest Date/Time <br /> 4. ❑ SANITATION PERMIT 'r- C �j � <br /> Job Address/Location L' A Xl <br /> Owner' - �i� `?C c1� Address ! 7,61 �/ <br /> MISEPTIC TANK ❑ CESSPOOL ' o LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑a NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Constcnction Disposal.Site <br /> No. of Units - Equipment $torage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 T— <br /> Operator Name ' Where Certified <br /> Plant Location . <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30. 19 ' .' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Thary 1,000 Sq. Ft. r O <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. _ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and re ations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �'- '---� <br /> �y FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT y PER SITE ❑ EACH ❑ January 1 a ei'ved Byd n ary 31 ❑ July 1 d Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE 5' AMOUNT DUE CHECKED <br /> DATE 9ATE MITT D AMOUNT <br /> FEE 5 h <br /> LESS � <br /> PRORATION AA <br /> PLUSM <br /> it <br /> PENALTY . 1 <br /> OTHER Yl <br /> OTHER <br /> 10761 Rs <br /> eceived Dnln y Date Receipt No. PerNo 1 ence ate <br /> uMailed Del <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />