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• Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> .� APPLICATION <br /> �h (For Non-Transferable, Revocable,and Suspendable) <br /> [! ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i ereb�made t c �+on iness in the juris 'ctional area of the Sa oaqu n Local Health Distn <br /> F Business Name BA} Address ,- e /-1'7F 7 - <br /> aOwner. Address <br /> 1 Firm Partners, Addresses and Telephone Numbers C!1 <br /> 4 Business Telephone No. /05 _ Emergency Telephone No. O <br /> Contractor Licence No. <br /> L Applicants Name (Print} Title Date <br /> Please check Applicable Category (1-7)and Fill in the Require 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 e <br /> 2. ❑ PUMPER YARD - � <br /> For July 1,= June 30, 19 j <br /> No. of Vehicles Stored <br /> - i <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ' <br /> R.S. or R.C.E. Name 0, R.S.or R.C.E. No. <br /> Test L cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addres, ocation S -2^ - �� �I� N <br /> Ow er— Address <br /> TIff IC NK NK ❑ CESSPOOL gL HING F ELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> r <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 Equipment Storage/Cleaning Locat� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 �' f <br /> Operator Name Q Vqhere 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 /> f i <br /> I hereby certify that I have prepared this application and that the work will be done in actor 6,e with San Joaquin County <br /> ordinances, state laws, and rule and regulations of the Joaquin Local Health District. , ^.' <br /> APPLICANT'S SIGNATURE X <br /> AA/ <br /> FOR DEPARTMENT USE ONL <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 14 Ja Lj y Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REM TA ¢ $ AMOUNT DUE CHECKED <br /> DATE fz/ REMITTED AMOUNT <br /> FEE ysov <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> old b a & <br /> Received by Date Receipt No. Permit No. I I Issuance Date Wiled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 959' <br />