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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ...,.. <br /> APPLICATION <br /> (For Non-Transferable;Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i ereby made o carry on busin ss in the'urisdictional area of the San Joaquin Local Health Dt t <br /> rBusiness Name A) Address 0Q &tf!'7d6 7 ..� <br /> aOwner Address -�---� <br /> Firm Partners, Addresses and Telephone Numbers <br /> 116 Business Telephone No— d Emergency Telephone No. fX1'J <br /> Contractor Licence No. z- <br /> LApplicants Nan r= Title Date "7— <br /> Please checkApplicable Category(1-7)and fill in the Requ red 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. LIC , se No. CAL. License Renewal No. <br /> Capacity 'f Gal.,Weights&Me ures No. <br /> s <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 FtS.or R.0 . N . <br /> Test L�tion est Dat Time <br /> 4. In SANITATION PERMIT <br /> Job Address/Loca 'on <br /> Owner Addr ss <br /> 13 TIC TANK ❑ CESSPOOL ❑ LEACHIN -FIELDOSAG;lT E, 'II4Fd <br /> PERMANENT ❑ TEMPORARY ❑ NEW * OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Dis osal Site <br /> No. of Units Equipment Stor a/Cleani(1g Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-Jude 30; 19 <br /> Operator Name W ere Certified <br /> Plant Location -• l <br /> Plant Capacity i. NQ.Un is Served;, <br /> ti <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 100 Sq. F. ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application arSd tha the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,and rul : d regulati s'ca't an J quinv66cal Health (strict. j <br /> APPLICANT'S SIGNATURE <br /> I <br /> FOR D PARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PA SITE EACH ❑ January 1 &Received By Januaryll 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION O T DUE' CHECK <br /> DATE DATE AMOUN <br /> FEE s <br /> LESS r ' <br /> PRORATION <br /> PLUS <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance 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 />