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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) SEPT,AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatiop,i's hereby de to car n busin ss In the jurisdictional area of the Joa in Local Health istrict <br /> F Busi a (DBA 3-�a " Addre s �" 4 <br /> a ° i <br /> Owner 1' ' 5- Address ©F i <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. ,j( -'g F.3,7 OA 2 <br /> �g Emergency Telephone No. SAI_ <br /> Contractor Licence No. 3 C 3 2 <br /> �Applicants Name (Print) T`C=4 � £ Title � �"�' Date,�2' 1��° ' °a <br /> Please check Applicable Category (1-7)and Fill in the Required Information + <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ) <br /> N <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 /> 1 <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 PERMI� <br /> Job Addr /Location T _ —" (('+�+� <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT El 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 /> I <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 have71 ,8 <br /> red this appli on and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a nd regulatio o e an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE 4❑EACH" -❑ January 1 R Received By January 31 July 1 &Received By July 31 <br /> REMIT <br /> EXPLANATIONEXPLANATION BILLING ', REMITTANCE - _ $ AMOUNT DUE CHECKED <br /> BASE <br /> DATE DATE REMITTED AMOUNT <br /> FEE ��— -) {�� <br /> t ^ <br /> .LESS i (`� <br /> PRORATION 1 <br /> I PLUS <br /> t PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> i Received by Date - Receipt No. Permit No. Issuance Date Mailed Delivered <br /> r <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />