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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 1A APPLICATION <br /> 1�j (For Non-Transferable, Revocable,and Suspendable) <br /> 1 ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application isbereby made to arty on busirless in the jurisdi tional area of the San Joaquin Local Health Dis rict <br /> r Business Name (DBA a Address 027,f l+ 7 <br /> Th <br /> z Owner �) Address <br /> 4 <br /> J Firm Partners, Addresses and Telephone Numbers - <br /> 5. Business Telephone No. �� /�� Emergency Telephone No. <br /> Contractor Licence No. - 2- <br /> Z <br /> �Applicants Name(Print) ,a C Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required nformation <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, ,lune 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. N <br /> Test ation Test Date/Time Q <br /> 4. SANITATION PERMIT W <br /> Job Address/Localion <br /> Owner -d-I Address !'� 3 Ola d <br /> 1:1SEPTIC T K ❑ CESSPOOL LEACHING FIELD EPAGE PIT <br /> ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 3 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site # <br /> No. of Units Equipment Storage/Cleaning Location(s) 5 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, June 30, 19 f <br /> Operator Name �-,.,Where Certified <br /> Plant Location <br /> s <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 /> 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, and rules a egulations Qf the SgrxJoaquin Local Health District. <br /> APPLICANT'S SIGNATURE X C{�f <br /> f <br /> FOR DEPARTMENT ONLY <br /> Fee Is Due: 1:1 ANNUALLY ❑ PER UNIT ❑ PER SITE El EAC January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING MITTANCE $ REMIT <br /> BASE EXPLANATION ATE DATE REMITTED AMOUNT DUE CHECKED <br /> + AMOUNT <br /> FEE �s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER �/ <br /> T v <br /> Received by Date Receipt No. Permit No. Issuante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITfSERVIC S 160 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />