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JY 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 /> Application is h eby made tp carry on business in the jurisdictional area of the SarJoaqyin Local Health District <br /> W Business Name (DBA) a- c � Address Ov'Or 7e T <br /> a Owner Address ` s <br /> 2.Firm Partners, Addresses and Telephone NumYers C <br /> aBusiness Telephone No._ e cam/8 Emergency Telephone No. i <br /> Contractor Licence No. oil <br /> . <br /> Applicants Name (Print) Title Date 0 <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 �.�."- _ .r.. -w--, • • -- �^... <br /> For July 1, i June 30, 19y <br /> No. of Vehicles StoredR' <br /> No. of Chemical Toilets Stored E <br /> �3. ❑ PERCOLATIONhTEST <br /> R.S. or R.C.E.-Name y ( R.S. or R.C.E. No. ii p <br /> Test LocationI <br /> ' ' Test Date/Time t a <br /> J. ❑ ON_SANITATIPERMIT <br /> ,Job Address/Loc tion <br /> Ow er _ Address 3 ���"- <br /> I� PTIC TANK ❑ CESSPOOL ACHING FIELD : SEEPAGE PIT ❑ PACKAGE PLANT -- <br /> V PERMANENT ❑ TEMPORARY IS NEW�" ❑ REPAIR ❑ OTHER (� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -� <br /> Type Construction Disposal Site <br /> No. of Units Equipme'n't 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 I M No.,Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30,719 . V. - „..;`s„n"'� <br /> a r { # <br /> SIZE: <br /> Less Than 1,OD0 Sq. Ft., ❑'4 More Than 1,000 Sq. Ft. �� f.'�J w. ^ <br /> ❑ DRY CLEANING, Chemicals Used/Amount/.Mo. r <br /> I hereby certify that I have prepared this application and that the work will be done'in accorr�e ith San Joaquin County <br /> ordinances, state laws, and rules and regMations of the San uin ocal Health District. <br /> f <br /> APPLICANT'S SIGNATURE X «" <br /> FOR DEPARTME T U_SE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE EACH/ ❑ anus 1 Rec ved 6 Jan 31 <br /> Y Y ❑ July 1 &Received By July 31 <br /> / V REMIT <br /> BASE EXPLANATION BILLING / REM AN _$+. —'°"' AMOUNT DUE CHECKED I <br /> DATE!I D E 'REMITTED AMOUNT <br /> J G H <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY t <br /> r _ <br /> OTHER <br /> OTHER <br /> /✓ <br /> Received by Date Receipt No Permit No. Issuance Date Mailed - /Delivered i <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />