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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) <br /> J� ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application ' reby made to carry on business in urisdictional area of the San Joaquin Local Health District <br /> HBusiness Name (DBA) ddress -7 <br /> aOwner Address C/ 401?1 � <br /> Firm Partners, Addresses and Telephone Numbers Q <br /> IL Business Telephone No. Emergency Telephone No. <br /> a � <br /> j Contractor Licence No. <br /> L Applicants Name (Print) Title ��� � ' Date S` <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 <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 Loc tion Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location s ' A46&, <br /> CA <br /> � <br /> Owner <br /> Address ` <br /> SEPTIC TANK ❑ CESSPOOL 'LEACHING FIELD yA,SEEPAGE PIT PACKAGE PLANT Op <br /> PERMANENT ❑ TEMPORARY XNEW ❑ REPAIR ❑ OTHER (A <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 9 <br /> Plant Location <br /> Plant Capacity No. Units Served to <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 /> t'c U-42671717 <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 ru n ulations of the San Joaqui Local HIVAth District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ JanAy 1 &Re a ved By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITT N $ REMIT <br /> BASE EXPLANATION DATE DA REMITTED AMOUNT DUE CHECKED <br /> �[ AMOUNT <br /> FEE -pc��yy L� <br /> LESS < <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER <br /> h <br /> 0algTReceived by ate cReceipt No. Permit o. L ssuanc Date( Mailed Delivered <br /> APPLICANT—RETURN'ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201— <br />