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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sig&The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH NRMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is reby made car rrbusiness in/�elurlsdictional area of th,�an quln Lo I /e�alth r' t <br /> y Business Name (DBA) �IIY�L� Address,f, �y (�,—�� I <br /> z Owner Address <br /> J Firm Partners, Addresses and Tele ne Numbers <br /> aBusiness Telephone No. Emergency Telephone No. p <br /> Contractor Licence No. -� <br /> a Applicants Name (Print) CA1 < �� l�J� Title s Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4W <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. C3 PERCOLATION TEST1-3 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 9 SANITATION PERMIT <br /> Job Address/Location <br /> Owner d Address -5�0, .144 <br /> _ <br /> SEPTIC TANK ❑ CESSPOOL W.LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY )NEW ❑ REPAIR ❑ OTHER C0 <br /> 5. 13 CHEMICAL TOILETS For July 1, -June 30, 19 �J <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: ❑ 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 and re u tions oft an Jgaquin 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 <br /> EMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION DATE DATE RE TED AMOUNT DUE CKED <br /> M LINT <br /> L.a? O <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY fAk Al" <br /> OTHER <br /> OTHER Q <br /> + ' L � <br /> Received by Date Receipt No. Permit No. Issuance Date M led Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES `.1601 E.HAZELTON AVE.,P_O.-Box 2009 STOCKTON,CA 95201 <br />