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. . �i. •,... r rr <br /> Applications Will Be Processed When Submitted Properly omp e e . <br /> APPLICATION <br /> Y 5 (For Non-Transterable, Revocable,and Suspendable) SEPTAGE <br /> -= ENVIRONMENTAL'HEALTH`PERMIT / <br /> LIQIIlIU•WASTE <br /> Application is tier by made t arry o business in a jurisdictional area of the �loaquin, I ealth Distric l <br /> (�' )qt. Address �f ,/� <br /> F Business Name (DBA) t Address �faS v s <br /> a Owner U (� _ < * ��'' <br /> 0 Firm Partners, Addresses and Tele hone Nu`b�Pr� Emergency Telephone No. ' <br /> a. Business Telephone No. <br /> J Contractor Licence No. Date <br /> Applicants Name (Print) <br /> (Q l7 Title {— <br /> "` d FIII In the Required Information <br /> Please check Applicable Category (1-7) an <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ---- x —Disposal Sites - T <br /> For July 1 " June 30,'19— <br /> Description`.(MakelYr.,Color) CAL License No. GAL. License Renewal,No. <br /> Serial No. <br /> Capacity Gal., Weights &Measures No. '`� <br /> v. _. <br /> EquipmentParking Address <br /> - 2. ❑ PUMPER YARD ' ' <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> Na. of Chemical Toilets Stored - '• 4 — i <br /> J � <br /> 3, ❑ PERCOLATION TEST - R.S. or R.C.E.No.`s � <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test cation k !_ t <br /> 4. <br /> Test <br /> PERMIT <br /> Job Address cation Address <br /> Owner <br /> 11 PACKAGE PLANT <br /> SEPTIC TANK CESSPOOL LEACHIN <br /> 11 SEPTIC <br /> G FIELD5EEP4GE PIT .v_ ; ; + <br /> ❑ NEW REPAIR ❑. r <br /> ❑ PERMANENT ❑ TEMPORARY 1 a ti <br /> 5. ❑ CHEMICAL TOILETS -For July 1, -June 30, 1D'sposal Site <br /> Type Construction . <br /> j Equipment Storage/Cleaning Lo�cationis? <br /> No. of Units <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1''-Judie 30, 19 Where Certified <br /> Operator Name 's - <br /> 41 <br /> Plant Location No. Units Served <br /> PI nt Capacity <br /> 7, ❑ LAUNDRY For July 1, -June 30, 19 , <br /> SIZE: <br /> C2 Less Than'1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft *. f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. C <br /> this app <br /> lication and that the work will be done in accordance with SanNSoaquin County <br /> —I hereby certify that I have prepar <br /> ules' d ulations f the San Joaquin Local Health'District. <br /> ordinances, state laws, and r <br /> s APPLICANT'S SIGNATURE X n O <br /> FOR DEPARTMENT USE ONLY <br /> i PER UNIT PE SITE ❑ EACH ❑ Jaruary_I &Received Hy-.anuary 31 .❑ July 1 &Received By July 31 <br /> [ 'REMIT <br /> Fee IS Due:.❑ ANNUALLY ❑ _ $ AMOUNT DUE„ CHECKED <br /> BILLING REMITTANCE AMOUNT <br /> i <br /> BASE EXPLANATION DATE DATE REMITTED <br /> At <br /> t FEE <br /> s 't <br /> f LESS <br /> f PRORATION <br /> I S PLUS P <br /> PENALTY <br /> e <br /> 4- OTHER c _ ?• <br /> OTHER . <br /> " .T_ lssu Ce pa Q ailed Delivered <br /> -_ Receipt No- PermitNo. ' <br /> Received by- Date -! ifi01 E.HAZELTON AVE.,P.O.Box 2409 STOCKTON,CA 95201 <br /> APPLICANT-RETURN ALL COPIES TO[ ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br /> __ <br />