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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> , - APPLICATION <br /> (For Non-Tfansferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) Address <br /> Q Owner--,(�,GQf,V-6 .CM l � Address `i 110 \11 t}t\�S , <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. f (n Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date - <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> li For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <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,I June 30, 19 <br /> No. of Vehicles Stored <br /> F No. of Chemical Toilets Stored <br /> t 3.,:❑ PERCOLATION-TEST <br /> R.S.or R.C.E. Name - " R.S. or R.C.E.'No.ti. <br /> Test Location Test Date/.Time - <br /> 4, ❑ SANITATION PERMIT -- — �" <br /> Job Add r /Location ' P7�b t,' <br /> Owner Address <br /> F SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEV1l El REPAIR--, OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 �. <br /> Type Construction ( Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) _ <br /> 6. ❑ PACKAGE TREATMENT PLANT Fpr July 1, -June 30, 1q <br /> Operator Name Where Certified = � <br /> Plant Location - <br /> - Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY Par July 1,'-June 30, 19 <br /> f SIZE: E] Less Than 1,000Sq.F{t+,` ❑ More Than 1,000 Sq. Ft. ' <br /> F <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> T I hereby certify that I have prepared this application and that the work will be done in accordance with Sa Joa In County <br /> ordinances state laws, and ru. s nd reguia s df t ' San Joaquin Local Health District. F <br /> k: <br /> APPLICANT'S-SIGNATURE X lir <br /> i <br /> 1=0R DEPARTMENT USi—ONLl(' _r <br /> Fee'js Due: ❑ ANNUALLY' _ ❑ PER UNIT ❑ PER SITE._._ .❑ EACH ❑-January 1.&Received By January 31 ❑,July 1 &Received By July 31 <br /> t BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATIONDATE DATE REMITTED AMOUNT DUE CHECKED <br /> _('+�.r -_ :,_• AMOUNT <br /> op <br /> FEET S f v <br /> LESS x. ✓ . ' <br /> PRORATION "" <br /> PLUS x ' <br /> PENALTY <br /> i F <br /> OTHIER <br /> k I <br /> OTHER <br />{ � - �ell /�`/'�((fes) /f^!�(� +/�// <br /> R ceived by Date Receipt No: Penni[No. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: . ,ENVIRONMENTAL HEALTH PERMITISERVICES --,1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />