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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 /> Applicatio s ie=on S=e e jurisdictional area of the S Joaqui cal Hoalt Dist <br /> ,�Business Df3A) Address - !J <br /> aOwner C Address���/__ a"• + �r1� ry <br /> zu Firm Partners, Addresses and Telephone Numbers 7VE 1.3/l <br /> Q. <br /> Business Telephone No. _Z61E.3 33 Emergency Telephone No. CJ <br /> Contractor Licence No. <br /> �Applicants Name (Print) IS-1--s- icer Title Oee2 z� Date b <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 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, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stared <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 /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location zo ' <br /> Owner e Address l <br /> L,'--',S�EPTIC TANK Cl CESSPOOL WI13LEACNG FIELD SISEEPAGE PIT PACKAGE PLANT <br /> L+f'PERMANENT ❑ TEMPORARY ❑ NEW RkNEPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ll <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <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 <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 /> I hereby certify that I have pre ared this applic n and at the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an es nd r gulatio o S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 3 \ <br /> REMIT Ds <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMDUNT <br /> FEE <br /> LESS nA \ <br /> PRORATION V" <br /> PLUS <br /> PENALTY \ <br /> OTHER <br /> OTHER <br /> No. <br /> Received by Date Receipt No. Permit Iss an a Date Mailed Delivered , <br /> �`- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.?.Poi 009STOCKTON,C©201 f <br />