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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - <br />`. APPLICATION I <br /> (For Non-Transferable, Revocable, and Suspendable) f <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio 's he eb to ca on b si ss in the jurisdictional area of the f t oa ''n Local lHHealth Di ict <br /> rn Business (DBA) Addre J <br /> UOwner f Address �p�// <br /> J Firm Partners, Addresses and Telephone Numbers C-/ / f <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 7 <br /> LApplicants Name (Print) Title fJGr?�y Date Z ` iZ4'�� <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) m <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 I <br /> No. Of Vehicles Stored <br /> No. of Chemical Toilets Stored a <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 Qk <br /> 4. I�S NITATION PERMIT �? <br /> Job Address/L cation <br /> O, nyler Address <br /> SEPTIC TANK CESSPOOL LEACHING FIELD 42-!�EEPAGE PIT PACKAGE PLANT <br /> 05—PERMANENT ❑ TEMPORARY [&NEW ❑ REPAIR o ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) 1 i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 J <br /> Operator Name Where Certified JJ <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 /> ) <br /> I hereby certify that I have pr d this applic n nd that the work will be done in acro e with San Joaquin County <br /> ordinances, state laws, a ule rid regulatio o e n Joaquin Local Wealth District. <br /> APPLICANT'S SIGNATURE X <br /> IF <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> a <br /> ec ived By January M ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REM AMOUNTDUE CHECKED <br /> BASE E7(PLANATION DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER F •- "�,. -...---.. <br /> _ OTHER - <br /> r <br /> _ ao 1 �1x� <br /> Received by - pate Receipt No. Permit No Issuance 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 />