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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> �I LIQUID WASTE <br /> i <br /> Application i rebs made car on business in the Aurisdictional area of thej n Joaa uin_Local Health Dis <br /> OF Business Name A) !s <br /> Add 7L 7 <br /> z Owner l ddress <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Emergency Telephone No. ` <br /> a Business Telephone No. k. <br /> Contractor Licence No. 3"'r-'e) �! <br /> Applicants Name (Print) I Title - Date <br /> Please check Applicable Category(1-7)and Fill in the Required int mation <br /> 1. ❑ PUMPER VEHICLE PERMITIiREGISTRATION (FOR EACH V HICLE) I <br /> For July 1 Ju e 3 ,19 Disposal Sites i <br /> Descripbon.(Make/Yr., Coolor)- <br /> i <br /> CAL. License Renewal No. <br /> Serial No - CAL. License No. <br /> ' � l+rri I <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD i6 <br /> For July 1, June 30, 19 <br /> f No. of Vehicles Stored <� <br /> No. of Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R. .E. Name II R.S. or R.C.E. No. <br /> II Test Date/Time P <br /> Test L ation I <br /> 4. SANITATION PERMIT <br /> Job Addre /Locatio , <br /> Owner Address <br /> d <br /> I'SEPTIC TANK 11C S POOL `EACHING FIELD SEEPAGE PIT <br /> D PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER- <br /> �i c A <br /> k 5. 1:1 CHEMICALTOILETS For"July 1,-June 30, 19 <br /> h Type Construction Disposal Site <br /> }, <br /> t No. of Units 111. Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT- For July 1, -June 30, 1,9 <br /> 1 Where Certified <br /> Operator Name - <br /> Plant Location <br /> J� 4 <br /> No. Units Served,'w <br /> Plant Capacity �. <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,006 Sq. Ft., ❑ More Than{1"000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that'I4have prepared this application and that the work will be done in accordance with San Joaquin County . <br /> ordinances, state laws;l and rules d regul ' ns of t San Joaquin Local ealth District. <br /> APPLICANT'S SIGNATURE X <br /> r zi� i <br /> t _ �1 <br /> FOR DEPARTMENT USE ONLY <br /> IEIEI ! <br /> Fee Is Due: ❑ ANNUALLY Ip ❑ PER UNIT ❑ PER SITE ❑ EACH' 't0{Jajuary 1 & eI By January 31 ❑ July 1 R Received By July 31 <br /> REMIT <br /> - EXPLANATION BILLING +,.,FREMlTTANCE*" ��.rr—AMOUNT-DWE— —CHECKED. <br /> BASE` <br /> I DATE DA REMITTED --- - — AMOUNT <br /> FEE qS <br /> LESS <br /> 1 PRORATION <br /> PLUS I� <br /> PENALTY <br /> OTHER <br /> k <br /> OTHERI� <br /> —S 5 <br /> i II <br /> Received by Date - Permi No. Issu nce ate Mailed Delivered <br /> Receipt No <br /> .F 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERTIT/SERVICES <br /> r <br />