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- Applications Will Be Processed When Submitted Properly Completed, BeSure io aign 1r��^Nr*r�•- ' <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> k.l <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE i <br /> Appl icat•on is hereby made to car on b sin in the ju isdictional area of the San Joaquin Local Health District f <br /> Address <br /> rBusiness Name {DBA) v <br /> Address ...•z <br /> Own - <br /> er- - <br /> ' <br /> ° Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> �- .. <br /> aBusiness Telephone No. - - <br /> Contractor Licence No. Tltle r + :Date <br /> 4 Applicarifs Name-(Print):F� - �-- <br /> 1 7 and Filt-in-the Required Information t- <br /> 'Please;check Applicable Category.( - ) <br /> ICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> T.= 1PUIIIIP�1fEH _ <br /> For July 1, ` June 30, 19- -- Disposal-Sites"_ <br /> I — - <br /> 11 Description(Makelyr.,Color) KCAL. License Renewal,No. <br /> Serial No. CAL. License No. -{ r <br /> k "Capacity Gal;'"Weights& Measares'No. <br /> Equipment Parking Address <br /> r <br /> 2. ❑ PUMPER YARD y <br /> For July 1, June 30, 19 <br /> No. of vehicles Stored_ „—_..�.:.. - ---r- � ^-- » ...r- �- -. ....`-�-` _ . ,� :.-,• <br /> No. of Chemical Toilets Stored • ' . <br /> k <br /> 3. PERCOLATION TEST r`Rr x <br /> R:S. or_ :C.E.No. <br /> R.S.or R.C.E. Name Test Date/Time <br /> Test'Location r <br /> t 4. 0 SANITATION PERMU,T 2 ` <br /> Job Address/Locati [ <br /> Owner Address t <br /> ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT El PACKAGE PLANTw t <br /> ❑ SEPTIC TANK' REPAIR ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY <br /> NEW <br /> 5. 1p CHEMICAL TOILETS For July 1,-June 30, 19 !. <br /> Type Construction ' Disposal Site <br /> `4; Equipment Storage/Cleaning Location(s) } <br /> r <br /> No. of Units c i/ J s <br /> r <br /> 6.'__E1 PACKAGE TREATMENT PLANT For July 1, -June 30_19- s- -Where Certified t <br /> Operator Name , ; ? <br /> I s � <br /> Plant Location -r."_.. <br /> No. Units Served _ <br /> .Pla t Capacity , <br /> 7•10 LAUNDRY For July 1�-June 30, 19---- Than 1,000 Sq. Ft. { <br /> SIZE: 11 L...Than 1,000q. Ft., 13 More - _^-- -- _.. +. - <br /> ❑•DRY CLEANING, Chem Icals,Used/Amount/Mo. <br /> _ _ p <br /> I hereby ce t 1 have prepared to application nd that the work will be done in accordance with San Joaquin County <br /> x ordinances, st. a laws, rules n re ti s f t San. aquin Local Health District. <br /> t . <br /> APPLICANT'S SIGNATURE X , <br /> i FOR DEPARTMENT USE ONLY <br /> s / 71)f ❑ Januar 1 &Received By January 31, "�� July 1 $Received <br /> Fee Is Due: ❑ ANNUALLY ❑;_PER UNIT, <br /> E]-PE EACH Y.. i RBILLING REMITTANCE F �$ - F AMDUNT DUE CH <br /> BASE EXPLANATION = _ DATE - DATE - - REMITTED-! � - AMOUNT <br /> FEEt'f <br /> 2_l <br /> i LESS {4 t <br /> PRORATION _ <br /> .. _i <br /> PLUS - f <br /> PENALTY t, <br /> OTHER <br /> 71 iki <br /> F OTHER_ } Y f <br /> Issuance Daie Mailed Deli red <br /> Date Receipt No Permit No <br /> Received by { - jgpl E.HA2ELTON AVE.,P.O.Box 2099 sTOCKTON,CA 95291 <br /> pppLICANT—RETURN ALL COPIES TO: ENVIRONME-NTAL�HEALTH PERN41lSERYICE _ <br />