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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATIONS - �r <br /> ' (For Non-Transferable, Revocable, and Suspendable) SEPTAGE i <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicat' is Thereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,n Business Name (DB ) 0/�' �B 0T-!5 U/eco' Address <br /> i Owner . f�FL CH Address -o T <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. ` <br /> Applicants Name(Print)►'��' Title 57Date <br /> Please check Applicable Category (1-7)and Fill in the fiequired Information <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 & Measures No, <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <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 _ y <br /> Job Address/Location I �1�-N/Vc� �j70---c 0, `AA•�� <br /> Owner Co. Address &d,(;!Fm C � <br /> ElSEPTIC TANK ❑ CESSPOOL 11LEACHING FIELD © SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 C <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <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.,_, ]..Morejhan,1,000,Sq. Ft., - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - -- <br /> I hereby certify thattI h ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws and and regulation of jhe Sa- Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r <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 /> —VtO10— "REM TTANC J $ REMIT <br /> BAS EXPLANATION GATE DATE' REMITTED AMOUNT DUE CHECKED <br /> S 11 AMOUNT <br /> FEE - <br /> LESS I t <br /> PRORATION <br /> PLUS f <br /> PENALTY <br /> x <br /> OTHER <br /> OTHER If <br /> F <br /> Received by Date Receipt No. Permit No. I suance Date - Mail Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 209 STOCKTON,CA 95201 <br />