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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION } <br /> (For Non-Transierable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> OF <br /> Applicatio t��e�ylrtle S to car i sines in thg4,urlis�dictional area of the S� a�guin� a� aGr�District <br /> H Business Na 'DBA) << GG,, 1' 1 J Address L3 <br /> 4 Owner "� ��2��1C Address I <br /> J Firm Partners, Addresses and Telephone Numbers <br /> abusiness Telephone No. - Emergency Telephone No. _ <br /> Contractor Licence No. ay3 d7!f <br /> LApplicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information o� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) i <br /> Serial No. CAL. License No. CAL. Liccase 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 /> I <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 /> I <br /> 4. ❑ SANITATION PERMIT <br /> Job Addre�5(,Lccation <br /> Owner [3II:2� `.'r'T'�R. r l Address 'e ' <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 0 PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER I <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal SiteQ� �Q� Cc' c �a ��$�"'� <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ^� <br /> Where Certified <br /> Operator Name l <br /> Plant Location <br /> Plant Capacity No. Units Served I <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 /> M <br /> I hereby certify that I have prepared this application and that the work will-be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the Sanoaquin Local Health District. �yLLQ <br /> �. �� <br /> APPLICANT'S SIGNATURE X <br /> IV <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE T-"l EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT< I <br /> e BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED - AMOUNT <br /> FEE <br /> LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> k. Received by DateReceipt No. Permit No. Issuance Date Mailed Delivered = <br /> APPLICANT--RETURN ALL COPIES TO: jNVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2000 STOCKTON,CA 85201 <br /> i <br />