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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION j <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> i <br /> LIQUID WASTE <br /> Application ' ereV made tp carry on siness in the ju dictional area of the San Joaquin Local Health Di ict <br /> F Business Name A) 2. Address `.. <br /> aOwner Address ��- i <br /> J Firm Partners, Addresses and Telephone Numbers <br /> E Business Telephone No.— � '/ate' Emergency Telephone No, <br /> Contractor Licence No. 07 <br /> L Applicants Name (Print. Title Date 5-,-7 <br /> Please-check Applicable Cat gory (1-7)and Fill in the Require Information <br /> 12 <br /> 1. ❑ PUMPER VEHICLE PERMITi'REGISTRATION (FOR EACH VEHICLE) — I <br /> For July 1" + June 30,Y19 Disposal Sites t 'i <br /> Description(Make/Yr., Color) A In 9! { <br /> Serial No. CAL. License No. CAL. License Renewal No. ' <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking'AAdress <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 /> I <br /> R.S. or R.C.E. Name I R.S. or R.C.E_ No. <br /> Test Location # II Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/ ocaYon _ _ <br /> • r <br /> Owner -- Address _� - - 0 <br /> 11SEPTICTANK ❑ CESSPOOL BLEACHING FIELD (� IT 11 PACKAGE PLANT , <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units E ui ment Stora e/Clea_nin Location(s) <br /> q- p - 9 �. 9 ( ) <br /> 6. ❑ PACKAGE TREATMENT PLANT fFor July 1, -June 30, 19 <br /> Operator Name Ar t + Where Certified , <br /> Plant Location �✓ # �� <br /> Plant Capacity 4. � S 1I No. Units Served t <br /> 7. ❑ LAUNDRY fFo,JR ly 1, -June 30„19 <br /> Than -- ^--- <br /> SIZE: ❑ Less ThaX000 Sq. Ft., ❑ More Than`1:000'Sq.Ft. <br /> ❑ DRY CLEAN ING7Chemicals Usetl/Amount/Mo. x : <br /> Ib <br /> 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'nd ru s and regulatio the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X II <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT _ ❑ PER SITE ❑ EACH ❑ January 1 &R:4Elyry 31 _ ❑ July 1 &Received By July 31 f <br /> { REMIT <br /> BILLING REMITTANCE BASE EXPLANATION DATE DATE UNT DUE CHECKED <br /> AMOUNT <br /> w <br /> FEECL <br /> LESS ;I T <br /> PRORATION g�. <br /> \\ PLUS <br /> PENALTY ' __ <br /> OTHER <br /> ER <br /> \ Date aj. "c.Receipt No. '�r� Permit No. Issuance Date Mailed Delivered - <br /> VET,URN ALL COPIES TO: ENVIRONMENTAL HEALTWPERMITISsERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 95201 k <br />