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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,I4etiodatAe,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> I LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br />,,Business ame (DBA) Addr <br /> f E ��f"z OwnerAddress � " <br /> J AW R"'Oon <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No, <br /> LApplicants Name (Print) �'2 I Title Date <br /> zz <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 Disposai Sites <br /> Description(Make/Yr., Color) - <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. o <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD { i <br /> For July 1, June 30, 19 I <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 I Test Date/Time <br /> 4. X SANITATION PERMIT ,I / <br /> Job Add ess/Location 1 �L�✓ "� V '" t'V fir" er <br /> Owner Y Address r <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLAN <br /> PERMANENT ❑ TEMPORARY KNEW ❑ REPAIR 15�Omaapsiu"{OS' <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 / ' <br /> Type Construction sl Disposal Site 4 <br /> No. of Units Equipment Storage/Cleaning Location(s)^ I <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 0 <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. '0 �u <br /> vA <br /> hereby certify that I have Eepared this application and that the work will be done in accordance with San Joaquin County r <br /> ordinances, state laws, a r es and regulations f th n Joa Local Health District. <br /> APPLICANT'S SIGNATURE -- <br /> ) <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH - ❑ January 1 &Received By January 31 ❑ July 1 &-Received By July 31 j <br /> '� BILLING REMITTANCE $ REMIT 91 <br /> BASE EXPLANATION DATE 'DATE REMITTED AMOUNT DUE CHECKED <br /> TE AMOUNT <br /> FEE <br /> LESS M <br /> PRORATION <br /> PLUS <br /> PENALTY ) <br /> OTHER k <br /> OTHER �e <br /> Received by -"' 'Date Receipt No.,. Permit No. ( Issuance Date Mailed Delivered f <br /> APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bow 2009- STOCKTON,CA 9 01 <br />