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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) SEpTAGE f P <br /> ENVIRONMENTAL HEALTH PERMIT G <br /> t LIQUID WASTE <br /> Application is hereby made t r n business in he j sdictional area of the San Joaquin Local ealth Distri t J <br /> y Business Name (DBA) Addres <br /> Address <br /> z Owner j <br /> a <br /> J Fitm Partners, Addresses and Telephone Numbers <br /> E Business Telephone No. <br /> Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) > Title �� Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information _ s <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Y <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> i <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 IV- <br /> No, of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST +r <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. 1 <br /> Test Location Test Date/Time <br /> 4. JIL SANITATION PERMIT . t <br /> Job Add r s/Location <br /> Owner " Address <br /> SEPTIC TANK ❑ GES OOL LEACHING FIELD El SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW.� ❑ REPAIR <br /> ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30; 19 _ - <br /> rType Construction �Dieposal Site <br /> k No. of Units EquipmenStorage/Cleaning Location(s) �1 <br /> F 6. ❑ PACKAGE TREATMENT PLANT For July t,_.June 30, 19 t <br /> Where Certified <br /> Operator Name 'i <br /> Plant Location. <br /> Plant Capacity No. Units Served s^� <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ` x <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County y ,4 <br /> ordinances, state laws, and Pules and regulati `!"r the Joaquin Local Health Districts <br /> APPLICANT'S SIGNATURE X zz ell <br /> FOR DEPARTMENT USE QNLY w*' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receiv,_ed y January 31 ❑ J 1 S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCES '$ pMOUDUE CHUCKED <br /> BASE EXPLANATION —R— -jL <br /> AMOUNT <br /> - DATE ,. ^'" DATE ��' REMITTED 4 <br /> s FEELESS <br /> + r- <br /> .rl� <br /> PRORATION <br /> PLUS ,. <br /> PENALTY <br /> F OTHER <br /> OTHER <br /> 7 i <br /> Received by Dat Receipt No. Permit No. Issuance to Mailed Delivered <br /> . ' - 'APPLICANT—RETURN ALLCOPIES T0:- ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009- STOCKTON,CA 95201 <br />