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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> APPLICATION <br /> Y— (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE } <br /> LIQUID WASTE <br /> Applica ion is hereby made to c rry on bus LA Hess i th jurisdictional area of thean Joaquin Lo al He Ith Distri t <br /> y Easiness Name (DBA} k y�+ Address �� <br /> z Owner t <br /> z Owner �� �. _ Address L <br /> L) Firm Partners, Addresses a lephone Num ers <br /> CL Business Telephone No. Emergency Telephone No. <br /> a- <br /> Contractor Licence No. Q 911 <br /> Applicants Name-(Print) Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information C <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAI . Lice ase Renewal No. <br /> 'Cap"acity =. w� - , ..._ Gal;Weights &-Measures No._ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <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.G.E. Name -R.S-'or,R.C:E:No. 1 ' <br /> Test Location _- Test Date/Time <br /> 4. ❑.SANITATION PER, ff_ O <br /> Job AddressLocat n �-�� <br /> O ner y '' Address <br /> XSEPTIC TANK ❑ CESSPOOL '— EACHING FIELD EEPAGE-PIT—13'PACKAGE PLANT <br /> PERMANENT _❑ TEMPORARY NEW ❑ REPAIR t ❑OTHER <br /> 5. ,❑ CHEMICAL TOILETS For July 1, - une 30;-119 <br /> Type Construction Disposal Site ( r <br /> No.of Units- . Equipment Storage/Cleaning Location(s) �y <br /> 6: ..❑ PACKAGE TREATMENT PLANT For July 1, -June:30, 19 € f <br /> Operator Name �- —Where Certified 11 <br /> Plant Location =- <br /> l. Plant Capacity No. Units Served j <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 i <br /> :4. SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. Y <br /> ❑-DRY CLEANING, Chemicals Used/Amount/Mo. # <br /> S <br /> I.hereby certify that I have prepared this applica 'on and that the work will be done in accordance with San Joaquin County { <br /> E g ordinances, state�Iawrules and- g quin Local Health District. �A0LICANT'S SIGNATURE h <br /> N Ile <br /> i <br /> FOR DEPARTMENT USE ONLY ' . <br /> r �r <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT 1:1PER SITE ElEACH 11January 1 &Received By January 31 ❑ July 1 &Received By July 31�. <br /> I• BILLING REMITTANCE $ REMIT ,r. <br /> BASE EXPLANATION DATE DATE REMITTED - - AMOUNT DUE CHECKED . p <br /> AMOUNT <br /> FEE <br /> - LESS _ <br /> PRORATION - <br /> � PLUS <br /> PENALTY - <br /> t. / N <br /> p OTHER i <br /> E r <br /> ` OTHER - - <br /> Received by ate - Receipt No.. ,, _ -.Permit No ,f f.Issuance Date Mailed Delivered <br /> -APPLICANT—RETURN ALL COPIES To: .ENVIRONMENTAL HEALTH PERMIT/SERVIC'ES '*W I• .;1601 E.HAZIIEILTONAI Box 2009 STOCKTON,CA 95201 !1 <br />