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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 4�' (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati n 91 leel�carry ofr�t,�sitl�Athejuripdi�ct,i+onal area of the S7r�iin L�II�I1eaf4jtiSist_riFt <br /> Business (DBA)_ 11 ( �f 7 `x -Address / { '�1 <br /> aOwner If6 1 Address 5- <br /> Firm Partners,Addresses and Telg1 � �ttr�yy Num er <br /> J . <br /> CL <br /> Business TelepFtone No. Emergency Telephone No. - <br /> d t <br /> Contractor Licence No. d{ <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information f <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. Liccnse 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 <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 /> Testi Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT / ..� D <br /> JobAddress/Lo ation �1G �1 cv,gfZ1. i � � _n <br /> Owner � /Prt`5 . 'ftp RAN St) Address i,2 6. S Mit-AJ #4CY A(--Iii <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 01 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) �t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> i <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. K <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, ales and regulation f the SaJoaquin Local Health District. J <br /> APPLICANT'S SIGNATURE X Li <br /> FOR DEPARTMENT USE ONLY l <br /> Fee Is Due_: 1:7 ANNUALLY. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT ; <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED„ <br /> i <br /> AMOUNT, <br /> 0-1FEE <br /> LESS d- <br /> PRORATION # <br /> _%. PLUS 1 <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> 4 <br /> I � <br /> Received by - Date Receipt No. .Permit Not Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2000 STOCKTON,CA 95201x,' ; <br />