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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) -n <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE w <br /> Application is her y made to car o usiness in the jurisdictional area of the an J a uin ac'dl Hdstrh ' ? <br /> rn Business Nam (DBA r Address <br /> 4 Owner - <br /> Address e9 Cya�sL . <br /> j Firm Partners, Addresses and Telephone Num ers I-, ` - <br /> aBusiness Telephone No. mergency Telephone No. <br /> Contractor Licence No. V <br /> 4 Applicants Name (Print) Titled e1 � Date -- <br /> .F <br /> Please check Applicable Categ ry ( -17) n ill in the Required Informs Ion <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) - <br /> For July 1, June 30, 19 qM, Disposal Sites <br /> Description(Make/Yr., Color) 11 ". <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address �M I <br /> 2. ❑ PUMPER YARD Q�5 <br /> For July 1, June 30, 19 M <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. <br /> Test Location �� Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> nl C <br /> Owner ss <br /> ❑ SEPTIC TANK b CESSPOOCI� ❑ LEACHING FIEL ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 11 TEMPORARY C1NEW 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) E <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name �M, Where Certified <br /> Plant Location <br /> Plant Capacity �M' No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -Junel , 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,1 '30❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 4 <br /> I hereby certify that I have prepared this applic ' n and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an cf rules and regulatio of he San Joaquin Loca alth District. <br /> APPLICANT'S SIGNATURE X �M° <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> t <br /> FEE LlSrC9d Cltf .IY <br /> LESS <br /> PRORATION I� k <br /> PLUS <br /> PENALTY <br /> OTHER f�� }f✓ I <br /> OTHER (I <br /> ?�F 7as-y 13/•v/�y <br /> Heceive6 by Date �II Receipt No. - P rmi[ o: Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E..HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> 12 va <br /> 3 <br />