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Applications-Will Be Processed Wh&i Submitted Properly.Completed. Be Sure To Sign The Application. <br /> �pPLICATION <br /> f(Por-Non-Transferable, Revocable,°and Suspendable) SEPTAGE <br /> "ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in-the jurisdictional area of the San Joaquin Local Health District <br /> FBusiness Name (DBA) A''-tf CQIVT f Address <br /> aOwner Address ._ ..: <br /> L) Firm Partners, Addresses and Telephone NumbersIL <br /> a Business Telephone No s - ;Emergency Telephone-.No. <br /> -J Contractor Licence No. 4�3 <br /> LApplicants Name (Print) Title„'., 'll, . . Date <br /> Please check Applicable Category.(1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <br /> For July 1,-- June 30, 19 -- —Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. M; CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking"Address ' `, <br /> 2. ❑ PUMPER YARD z <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored r <br /> ;c <br /> No. of Chemical Toilets Stored , <br /> 3. ❑.PERCOLATION TEST y <br /> R.S. or R.C.E. Name <br /> Test Location i - Test Date/Time <br /> 4. yu SANITATION PERMIT <br /> Job Address/Location <br /> Owner r Address <br /> ❑ SEPTIC TANK ❑ CESSP,OOL'*'' ❑ LEACHING FIELD 13 SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11PERMANENT ❑ TEMPORARY ❑ NEW " -. 1. REPAIR OTHER <br /> � (111111 <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 t 1 <br /> Operator Name _ l�` - f` Where Certified <br /> Plant Location <br /> Plant Capacity r �. No. Units Served I <br /> '7. ❑ LAUNDRY For July 1, -June 30, 19- <br /> SIZE: <br /> 0, 19 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.,Ft:�1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> j r .I i 4� L <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 regulations of the '"Joaquin Local Health District. <br /> 9 <br /> APPLICANT'S SIGNATURE <br /> _ t . <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT" ❑ PER SITE ❑ EACH ,❑ January 1 &Received By January 31 ❑"July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE OHECKED <br /> + f DATE DATE 'REMITTED AMOUNT <br /> FEE- <br /> LESS <br /> EE LESS i 4 <br /> PRORATION' <br /> PLUS <br /> PENALTY' 1' T <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, r Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:– ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> C rdS✓ <br />