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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE f <br /> Applicatio Is h eby adIe�toAc�ar�on business In the i risdictional area of the�ASan Joaquin Local Healt Di trict <br /> OFBusinessName (DSA) s � � i( ,p, _Address—V-0- A; LV-M �. <br /> aOwner Address <br /> Firm Partners, Addresses and Tel ne Nu tiers <br /> aBusiness Telephone No. — 0�. Emergency Telephone No. <br /> Contractor Licence No. `f <br /> L Applicants Name (Print) -7 <br /> Title Date <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 Disposal Sites <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 ' <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.C.E. Name R.S. or R.C.E. No. •I <br /> Test Location Test Date/Time W <br /> 4. T` SANITATION PERMIT W <br /> Job Add re /Location <br /> Owner Address d i ' <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 14,SEEPAGE PIT ❑ PACKAGE PLANT t� <br /> PERMANENT ❑-TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. <br /> 11 CHEMICAL TOILETS For July 1, -June 30, 19 �+ <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) 1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rules and reg lationsa San Joaquin Local Health .District. <br /> 10 <br /> APPLICANT'S SIG TUBE X <br /> - <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Fee IS Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE - DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION 1 <br /> PLUS <br /> PENALTY <br /> OTHER s <br /> OTHER 1a1 <br /> 0 01-51tL67/yn <br /> 1 <br /> Received by Dale.. <br /> ate Receipt No Permit No. - ssuanc Date Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Box 20D9 STOCKTON,CA 95201 <br />