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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 ereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OBusiness Name (DBA)---i s Address <br /> z Owner ..r 2 Address r� <br /> f" '-f W- <br /> Firm Partners, Addresses and Telephone Numbers _ <br /> a. Business Telephone No. 17 'S Emergency Telephone No. 1 <br /> Contractor Licence No. <br /> L Applicants Name (Print) ,"C � �� Title ,dc"�' 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 PERMIT <br /> Job Address/ ocation <br /> Owner Jef9Oki 04f Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD _ ❑ SEEPAGE PiT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ 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 /> I hereby certify that I have prepared t s application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules andAg rtions f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> %b <br /> 1 FOR DEPARTMENT USE ONLY <br /> El Fee IS Due: ❑ ANNUALLY PER UNIT 1694 PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> RE�IVT4T <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION f AMOUNT DUE CHGRED <br /> { DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER J� <br /> OTHER <br /> 6 53 5 `� d <br /> Received by Date Receipt No. Permit No. Issuanice 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 />