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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati ereby ma t carryo busin ss in the jur 'ctional area of the JOa uin Local Health District <br /> ,�Business Name A) <br /> aOwner O Address <br /> Address <br /> Firm partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. 516 f <br /> j Contractor Licence No. Emergency Telephone No. <br /> L Applicants Name (Print) <br /> Title Date � 6 <br /> Please check Applicable Category(1-7) and Fill in the Requi d Information <br /> 1• . PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) p, <br /> f1 For J'" 1� June 3 10 9 (' <br /> f U Disposal Sites <br /> Description(MakeZYr.,.Color) <br /> Serial No. f� CAL. License No. <br /> Capacity ' CAL. License Renewal No. <br /> GaIWeights & Measures No. <br /> Equipment Parking Address . . <br /> 2. ❑ PUMPER YARD <br /> For Jul 1, 1'k <br /> Y June 30, 19 <br /> No. of Vehicles Stored' <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R. .E. Name . R.S. or R.C.E. No. Y# i <br /> Test L ation Test Date/Time <br /> 4• ffl SANITATION PERMIT /� <br /> Job Addr s/Location 29.5-1 121,� <br /> Owner <br /> 11SEPTIC TANK ❑ CESSPOOL +-r LEACHING FIELDdress r <br /> 11 PERMANENT EITEMPORARY 11 NEW �T 11PACKAGE PLANT <br /> 5. El CHEMICAL TOILETS For July 1, -June 30, 19EPAIR OTHER <br /> Type Construction Disposal Site <br /> Na: of Units -- 1 <br /> Equipment Storage/Cleaning Location(s) Th. , <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 I <br /> ...... ...�. L r <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 5q. Ft., ❑ More Than 1,000 5q. Ft. <br /> © DRY CLEANING, Chemicals Used/Amount/Mo. ? ....,,..�>� ,.� •� <br /> 1 k { ,1 <br /> Itt <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wi&rSan Joaquin,County <br /> ordinances, state laws, and ru sand re,g/uJlati0 of the San Joaquin Local Health District. 4 <br /> APPLICANT'S SIGNATURE X <br /> f <br /> f _ } <br /> FOR DEPARTMENT USE ONLY ! <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE 13 EACH <br /> ❑ January 1 &Received By January 31•.,,, July 1 &Received By Jufy 31 <br /> BASE EXPLANATION BILLfNGREMfTTANCE $ _ REMIT <br /> DATE DATE. REMITT AMOUNT DUE CHECKED <br /> FEE �,L(� - _ — — —_ <br /> _AMOUNT <br /> LESS d ; <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, <br /> Issuan a Date Mailed Delivered <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTDN AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />