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Applications Will Be Processed When Submitted Properlytompleted. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> _ ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application her by de to car n busi(�-ess In the jxrisdictional area of th arl J quin Local TIM pct <br /> H Business Name (DBA) • ��!/ �. .G�c� Address �`. � fs� . �• ���! <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �b ���7 Emergency Telephone No. ' <br /> Contractor Licence No. �^ <br /> Applicants Name (Print) I o - Title A Date 4 y <br /> Please check Applicable Category (1-7)and Fill in the Required Information Q' <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ( f <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL, License No. _CAL. Licc;lse 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 3, <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 cation - Test Date/Time, <br /> 4pi SANITATION PERMIT t <br /> Job Adocation _ <br /> dres 3 <br /> O ner Address <br /> SEPTIC TANK •❑ C SSPOOi LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT O <br /> Y PERMANENT ❑ TEMPORARY 9NEW .❑ 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) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <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: <br /> 9 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. �f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 2�1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sa oaqu n County : <br /> ordinances, state laws, anq rules and regulation the S oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 r <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> U <br /> FEE f� G— <br />_ <br /> LESS <br /> PRORATION <br /> PLUS <br /> Val- <br /> PENALTY !� <br /> OTHER <br /> OTHER 4 <br /> - b <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered. 1 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E-HAZELTONAVE.,P.O.Box 2009 STOCKTON,CA 95201 r <br />