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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) A <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i ereby made t carry on business in the juris ictional area of the San Joaquin Loca!Health D'strict O <br /> wBusiness Name (D A) Address 2 <br /> z Owner <br /> � Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. - V Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) *A- Title Date ... 10 -7 <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 v <br /> No. of Chemical Toilets Stored \J <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test cation Test Date/Time N <br /> 4. SANITATION PERMIT _ <br /> Job Address/Locat' n ReA <br /> Owner Address r! 2- <br /> ❑ SEPTIC TQNK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW Q REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -4— <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) T-� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 1 <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 /> I 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 2e regulations of th n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: © ANNUALLY ❑ PER UNIT yx PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> T DUE <br /> FEE `/S <br /> LESS <br /> PRORAI"ION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Ca Z5O <br /> X10 9 7 <br /> Received by Date Receipt No. Permit Na. 1 seance ate Mailed Deli®r , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMIT/SERVICES 1 01 E.HAZELJON AVE.,P.O.Bo:2009 STOCKTO CA 9$261 <br />