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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 y� <br /> LIQUID WASTE ` <br /> Application is h eby made to carry on business in the'urisdictional area of the San Joaquin Local Health District <br /> ,Business Name (DBA) Address <br /> aOwner Address i <br /> J Firm Partners, Addresses and Telephone Numbers <br /> i a Business Telephone No. — @ S Emergency Telephone No. <br /> f Contractor Licence No. 3 Z —2—2- 6 ' <br /> Applicants Name (Print) r Title Date 7� ` <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> I 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,'' June 30, 19 Disposal Sites I <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No, <br /> Equipment Parking Address I <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored. <br /> Ate= <br /> I 3. ❑ PERCOLATION TEST <br /> l R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> I Test Location Test Date/Time <br /> 4. 9 SANITATION PERMIT Z' <br /> Job Address Location $q 4 q <br /> Owner 411Ld.1f_ Address/ . 41 <br /> 18-SEPTIC TANK ❑ CESSPOOL EACHING FIELD 'LJ IT ❑ PAC GE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY l{1 NEW ❑ REPAIR ❑ OTHER <br /> I 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> l Operator Name " Where Certified <br /> Plant Location a <br /> Plant Capacity No. Units Served `- <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 } <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> l ordinances, state laws,:and.rules and egulations of the n Joaquin Local Health District. <br /> l <br /> APPLICANT'S SIGNATURE X <br /> i - - <br /> FOR DEPARTMENT USE ONLY <br /> FeeIsDue: ❑ ANNUALLY © PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> SASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> p OTHER <br /> 1 OTHER <br /> I - <br /> �-S6 53 <br /> 1 <br /> h - Received by- Date - Receipt No. - 'erm'�t No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES — _A601 E.HAZELTON AVE.,P. Bax 2009 STOCKTON,CA 85201 <br /> 1 �� 2 <br />