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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Nan-Transferable, Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ! LIQUID WASTE­ <br /> Application is herebyjpadl,to carry on bus ln ss in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name{DBA} GL Address <br /> aOwner . < ;F,-AC G 4=- a . ..Address <br /> Firm Partners, Addresses and Telephone Numbers - <br /> aBusiness Telephone No. 'b V%�) Emergency Telephone No. <br /> Contractor Licence No. 7,r " <br /> a Applicants Name (Print) - <br /> L Title95� _ �,� Date t <br /> Please check Applicable Category-(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) _ <br /> For July 1, June,30, 19 T Disposal Sites - Y f <br />{ Description(Make/Yr., Color) ' <br /> Serial No. f CAL. License No. CAL. License Renewal No. t <br /> Capacity i Gal., Weights & Measures No. f <br /> Equipment Parking Address` ' <br /> 2. ❑ PUMPER YARD <br /> For July 1, ` June 30, 19 j <br /> No. of Vehicles Stored i 1 <br /> No. of Chemical Toilets Stored j <br /> 3. ❑ PERCOLATION TEST i <br /> R.S. or R.C.E.�Name R.S. or R.C.E. No. ' <br /> Test Locations Test Date/Time f <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owne C Address _ <br /> SEPTIC TANK <br /> E] CESSPOOL t ,ACpHING FIELD ❑ SEEPAGE PIT-.❑ PACKAGE PLANT <br /> 1:1 PERMANENT ❑ TEMPORARY ❑ NEW r❑ t}EpAtR ❑ OTHERS j -G <br /> 5. ❑ CHEMICAL TOILETS For July 1,'-June <br /> Type Construction I �t Disposal Site <br /> No. of Units n Equipment Storage/Cleaning Location(s) Z ! J t <br /> 6. ❑ PACKAGE TREATMENT PLANT For'July 1, -June 30, 19 4 <br /> Operator NameWhe ' rtified s <br /> Plant Location I Ce <br /> Plant Capacity f No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑; More Than 1,000 Sq.,Ft. � <br /> ElDRY CLEANING,Chemicals Used/Amount/Mo. "e <br /> i ,,��' R t <br /> I hereby certify.that I have prepared this application and tha.fthe work will be done in-accordance wi ' Sa a in �nty <br /> ordinances, state laws, and rules and rulaof file 5'n``Joaquin Local Filealth District. , ! <br /> �:.� <br /> APPLICANT'S SIGNATURE X t t i <br /> li l FOR DEPARTMENT USE ONLY # i <br /> Fee Is Due: ElANNUALLY Q PER UNIT PER SITE LJ EAC ❑ January 1 &Received By January 31 _0 4July 1 &lReceived By July 31 <br /> E BASE 1 xFLANAT,�N BILLING REMITTANCE! S 1 REMIT <br /> e i .,. _ ©ATE } t AMOUNT DUE CHECKED <br /> DATE ' REMITTED AMOUNT <br /> FEE <br /> - j s <br /> LESS <br /> PRORATION' <br /> PLUS <br /> x" PENALTY 4- <br /> OTHER ;ML <br /> 0TH ER_— <br /> Received by - Date 'Receipt No, - Permit No. Issfiance D te� Mailed Delivered . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -r 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />