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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 /> p 42-10- <br /> � /� ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> - `' 2-1�/ LIQUID WASTE M <br /> Applicata is ereby a to arty on sinessrl the jurisdictional area of the San Joaquin Lo I Healt Dis i <br /> I-Business Na a (DBA) Addre <br /> aOwner Address <br /> j Firm Partners, Addresses and'T Ig phone Numbers <br /> CL Business Telephone No. `CR6_1 l 6 Emergency Telephone No. <br /> Contractor Licence No. <br /> ti e� Y <br /> 2 LApplicants�N$me (Print)NON ! Title IeFsr Date �11 <br /> Please chef Appiicabl 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. SAL License No: CAL. License Renewal No. t <br /> Capacity IGal., Weights-&Measures No. <br /> Equipment Parking Address i <br /> 2. ❑ PUMPER YARD` <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. 11 PERCOLATION TEST <br /> R.S. or R.C.E. Name 414s M 9% e^tkIO-R,S. or;R:C'E; N4� ,`+, <br /> +rat 1%. .�. 4' V 4• '4 � <br /> Test Location Test Date/Time - '' <br /> 4. SANITATION PERMIT --( <br /> Job Add, /Lo <br /> Owner Address— <br /> SEPTIC TANK <br /> ddressSEPTICTANK ❑ CESSPOOI ❑ LEACHING FIELD-13-SEEPAGE-PIT :--E]-PACKAGE LANT <br /> C I)l PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June-3_'O, 19 <br /> Type Construction Disposal Site <br /> No. of Units I Equipment Storage/Cleaning Location(s) <br /> F 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.IFt. <br /> i ❑ <br /> DRY CLEANING, Chemicals Used/Amount/Mo. T" <br /> I hereby certify that I hale prepared this a'expplication and that the work will be done in accordance with.San Joaquin County <br /> ordinances, state lawA.TwIes, <br /> ndfeg lations of the San Joaquin Local Health District. <br /> f <br /> APPLICANT'S SIGNATURE X u <br /> FOR DEPARTMENT USE ONLY #i <br /> Fee Is Due: 11'ANNUALLY ❑ PER UNIT( © PER SITE kk- ElEACH ❑ January'I &'Received By January 31 ❑ July 1 &Received By July 31 <br /> 0, 13ILLIING REMITTANCE $ {REMIT <br /> 1 BASE EXPLANATION t - i DA E REMITTED AMOUNT Df E CHECKED <br /> DATE <br /> AMOUNT. <br /> 4 <br /> 3 FEE <br /> LESS 1 <br /> I PRORATION <br /> PLUS <br /> PENALTY L + <br /> OTHER I e <br /> t OTHER t t <br /> S <br /> Received by Date Receipt No. Permit No. I Issua Vice Date Mailed Delivered <br /> APPLICANT—RETURN ALL.COPIES TO:.,ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20 STOCKTON,CA 96201 <br />