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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 /> 1 LIQUID WASTE <br /> Applicatyi � is hereby made to ca on business in the jurisdictional area of the San Joaquin�L�al h District �( <br /> F Business Name (DBA)! {LY®LbCk�tLjR ca� Address 3�2 /�. �� fLt1 . <br /> aOwner Address <br /> Firm Partners, Addresses and Tele ne Numbers <br /> a. Business Telephone No. SL Emergency Telephone No. <br /> Contractor Licence No. <br /> of <br /> L Applicants Name (Pri Titicow� e Date <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 Location Test Date/Time <br /> 4. ❑ SANITATION PER T <br /> Job Addres cation 4 IAVA <br /> Owner V"UAddress C. <br /> ❑ SEPTIC TANK A ❑ CESSP L � EAG FIELD SEEPAGE PIT El PACKAGE PLANT <br /> 11 PERMANENT 11U TEMPORARY EW ❑ 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) <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 prepa this application the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r d regulations Joaqu' cal 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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ZZC-_&-A,7 <br /> LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER / <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issua ce Rate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL ON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ''� <br />