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~ - Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transierable, Revocable, and Suspendable) <br /> SEPTAGI; <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQU10 WASTE <br /> Application 's hereby m e to carryon siness in jurisdictional area of the Sap�oa Local 'strict <br /> OABusiness Na BA} T 'f- Addres <br /> Address <br /> 10 <br /> aOwner_— — E �• <br /> 0 Firm Partners, Addresses and Telephone Numbers 3� <br /> aBusiness Telephone No. 3� Emergency Telephone No. <br /> Contractor Licence No. <br /> 49 <br /> Applicants Name (Print} �E Title Date Q <br /> Please check Applicable Category (1-7)and Fill in the Required Information I" <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites { <br /> Description(Make/Yr., Color) <br /> Seriai No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> I� For July 1, June 30, 19 <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.G.E. No. <br /> Test Location <br /> Test Date/Time <br /> 4. E SANITATION PERMIT _ l <br /> Job Addres Location ` U o <br /> Ow r Address ^^ <br /> &K <br /> �SEPTIC TANK C1 CESSPOOL ACHING FIELD 1:1 SEEPAGE PIT C1 PACKAGE PLANT —jLKPERMANENT 11TEMPORARY NEW 1113REPAIR OTHER V' <br /> I 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 0' <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 /> Where Certified <br /> Operator Name <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 /> 4 <br /> ii <br /> f <br /> I hereby certify that I have prepared this a Icatio and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a and u 1 o e San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 1-1ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 E] July 1 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> + 0 <br /> r <br /> [FEE ALESS <br /> + PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 39 ID- <br /> -,,,,—ev—ed 6y pate - Receipt N. Permit No. I suance De Mailed Delivered <br /> IAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />