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Applications Wilt Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> =� (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> / ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application-�I hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> w Business Name (DBA) (70'6e '7�c5 O'NS C-6fJsr Address �� A• 4A uIA-)K g f- <br /> aOwner SAAC4e e ddress 9 / 5,7 <br /> Firm Partners, Addresses and Teleph ne Numbers <br /> aBusiness Telephone No. 9 —c2 a2— Emergency Telephone No. <br /> Contractor Licence No. — <br /> Applicants Name (Print) Title A4 RT e`Z Date <br /> Please check Applicable Category(1-7)an Fill in the Required Information 67 <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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location a <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT T <br /> ❑ PERMANENT 11 TEMPORARY 11 NEW ❑ REPAIR ,OTHER ,Q�'�T—RaS� J-�/QT� /i�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 <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 r s and regulations of YV San Joaquin 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE ( � 1416 <br /> LESS /t� <br /> PRORATION l� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � Ay 0,1_o <br /> Rec ived by Pate 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 />