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Applications Will Be Processed When Submitted P:ropa�, ompleted. Be Sure To Sign The Application. <br /> APPLICATION <br /> • (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT C-6,g)?&C -o 6pry <br /> LIQUID WASTE <br /> Application ir;4 ereby madea caruv en business in the jurisdictional area of th an 4paquin Local H Ith District <br /> Business Name (DBA) t. ✓l ''`'�'✓ Address_ �- <br /> z Owner c Address <br /> a . <br /> u Firm Partners, Addresses and Tf I ph ne Numbers <br /> a Business Telephone No. �6 b! Emergency Telephone No. <br /> -44U z <br /> Contractor Licence No. s" <br /> L Applicants Name(Print) Az 90 - - Title `s Date ' <br /> Please check Applicable Category(1-7)and Fill in the Required Information /J <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �1 <br /> For July 1,_ June 30, 19 Disposal'Sites - <br /> Description(Make/Yr., Color)- <br /> t <br /> Serial No. CAL. License No. CAL. License Renewal No. \� <br /> Capacity Gal., Weights &�M,easures No. <br /> Equipment Parking Address_ v <br /> 2. ❑ PUMPER YARD IJ <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 i R.Se or R.C.E. No. <br /> Test L cation' ` Test Date/Time ) <br /> 4. SANITATION PERMIT <br /> Job Address/ ocation -gr-oo <br /> O ner C"Jf3�f UL7I� 111,4W Address C �'"r e1� �►%' <br /> SEPTIC TANK ❑ CESSPOOL V LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKErPLAIVT <br /> PERMANENT ©TEMPORARY NEW ` t �a REPAIR ❑ OTHER 9 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site i <br /> No. of Units t I Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Y <br /> € Where Certit ed <br /> Operator Name---- --- — - <br /> � t <br /> Plant Location _ <br /> Plant Capacity No. Ur Its Served <br /> 7. 11 LAUNDRY For July 1, -June 30, 19ja I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.'FT. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount%Mo. <br /> �4Z !} <br /> I herebq_cbA fy�jhat I have prepared tliis application and that the:work will be done Ir]•'accordance with,San Joaquin County <br /> ordinances, state laws, and.r_a_rles and regulati-ns of th6,,San Joaquin Local Health District.S;WI% �. <br /> APPLICANT'S SIGNATURE X. ) <br /> J C2 <br /> t , <br /> FOR DEPARTMENT USE ONLY <br /> 3 ` _ 30_ ._ <br /> Fee Is Due: El ANNUALLY El PER UNIT? ❑ PER SITtt--'0 EACH 113anuary Received By January 31 ❑ July41'&_Received By July 31 <br /> - '`• REMIT <br /> BILLING REMITTANCE f AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEELESS <br /> € .� -.-.�.,�._-.� ��,�...-L.-. --ate.. + --•rte. .a.-.-a..,,-.—. ....,....... .^,....., <br /> PRORATION <` L-y <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date _.1 k._j Receipt No. Permit No. - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZ£LTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />