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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> �I LIQUID WASTE <br /> Application i ereby made o carry on usiness in the ju sdictional area of the 5a oaquin Local Health Distric <br /> Business Nam DBA) Address —E <br /> aOwner Address - a <br /> J Firm Partners, Addresses and Telephone Num re gr, <br /> M <br /> Business Telephone No. 30 s—/O 5 Emergency Telephone No. 1 <br /> 4 Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7}and Fill in the Req fired Information `�- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) � <br /> For Julyi4l. June 30, 19 I� Disposal Sites <br /> Description(Make/Yr., Color) <br /> I Serial No i 41, 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 I' <br /> No. of Vehicles Stored I� <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST # <br /> R.S. or R.C.E. Name I t <br /> R.S. or R.C.E. No. <br /> Test Location A. t I <br /> Test Date/Time 1177�, <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/ cation > �} <br /> Owner , f Address 0 # { <br /> SEPTIC TANK ❑ CESS OL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY (©/NEW ❑ REPAIR ❑ OTHER q e, <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ` M <br /> Type Construction Disposal Site l <br /> No. of Units Equipment Storage/Cleaning Location(s) is <br /> 6. ❑ PACKAGE TREATMENT PLANT For Julyfl, -June 30, 19 G <br /> Operator Name II ' .9 ( s <br /> Where-Certified*y <br /> Plant Location II 1 `1 r <br /> Plant Capacity T )Z S € ) <br /> No. Units Served rn <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 <br /> f1 , <br /> SIZE: El Less Than 1,000 Sq. FE.�� ❑ More Than 1,000 5q. Ft. <br /> ❑ DRY CLEANING, Chemicals Used%Amount/Mo. • ° 1 t n <br /> P � <br /> :i <br /> I hereby certify that I have prepared this application and that the work will be donelin accordance wit#> San Joaquin County a <br /> ordinances, state laws, and rules and regulation f the San Joaquin Local Health District pt-Iv]' <br /> t. I F <br /> APPLICANT'S SIGNATURE X <br /> r <br /> a <br /> F <br /> FOR DEPARTMENT USE ONLY 11' <br /> Fee Is Due: ❑ ANNUALLY ❑:,PER UNIT PER SITE ❑ EACH - ❑ Janutry 1 & e e' d By Januar <br /> y 31 ❑ July 1 &Received By July 31 <br /> BASE III EXPLANATION BILLING REMITTANC $ REMIT <br /> r DATE DA REMITTED AMOUNT DUE . CHECKED <br /> FEE I AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> Id I. <br /> OTHER R <br /> II - <br /> OTHER <br /> I <br /> i ti <br /> i, U/ V <br /> Received by Date Receipt No. - Permit No. - Issuance Date Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 . <br />