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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 /> t�v ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQ41D WASTE <br /> Application 41ertmade t rry on ess i e jurisdictional area of the San Joaquin Local Ith ist ' t <br /> H Business Na (DBA) Address d <br /> z Owner Address <br /> a _ <br /> a Firm Partners'Addresses and Telephone Numbers <br /> aBusiness Telephone No. 6 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name(Print) Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required nformation <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. Licc.-lse Renewal No, j <br /> Capacity Gal., Weights & Measures No. G <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD �( <br /> For July 1, June 30, 19 p� <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. 0 SANITATION PERMIT <br /> Job Address 9ca n `-iW <br /> Owner Address <br /> SEPTIC TANK ❑ CESS OL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT P <br /> PERMANENT ❑ TEMPORARY 13 NEW ❑ REPAIR <br /> ❑ OTHER j <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. 13 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 epared this application and that the work will be done in accordance with San Joaquin ounty <br /> ordinances, state laws, r sand regul tion of the S J aquin Local Health District. '€ <br /> � n <br /> -.o <br /> APPLICANT'S SIGNATURE X <br /> C,,Aa <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received 6, January 4-11_. July 1 Received By July 31 <br /> BILLING REMITTANCE $ REMIT -.1 <br /> BASE EXPLANATION DATE GATE REMITT AMOUNT�DUE �; C EGKE <br /> A OU <br /> FEE �S <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r Received by Date Receipt No. ermit No ISS ante ateai tl Delivered <br /> Y APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH,PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.. 009 STOCKTON,CA 95201 ^ <br />