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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby maAe to carry, business in the jurisdictional area of the Sz%Joawon Local Health rict <br /> F Business N e (DBA Addresses <br /> I- IF // <br /> z Owner " £�£ Address <br /> 47 <br /> Firm Partners, Addresses and Telephone Numbers 71/��.36e� <br /> 0. Business Telephone No. 3 6-F'3s3" Emergency Telephone No. � <br /> Contractor Licence No. <br /> Applicants Name (Print) Title G% �j� - 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 Rencwal 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 <br /> Owner Address3 s. C4_ C> <br /> SEPTIC TANK ElCESSPOOL BE�LEACHING FIELD SEEPAGE PIT PACKAGE PLANT <br /> a PERMANENT ❑ TEMPORARY U-NEW ❑ 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 /> 1 hereby certify that IXanules <br /> pare this applicati a th t the work will be done in accordance w' San Joaquin County <br /> ordinances, state lawscl reg lations oaquin 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 & ec . By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE EMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LAS c � s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> V <br /> OTHER <br /> s <br /> Received by Date Receipt No. Permit No. Is u n to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA ELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />