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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 A <br /> Application is hereby made to carry on business in the jurisdictional area of the an Joaquin Local Health District _ <br /> Business Name(DBA) t { Som Address /3nY <br /> i Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. S' Emergency Telephone No. <br /> .7 - y�� y <br /> �Contractor Licence No. <br /> / CG^ 5"Ffb <br /> L Applicants Name (Print) Title Date t� 1 <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 Stored <br /> 3. ❑ PERCOLATION TEST Q <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. M SANITATION PERMIT O S <br /> Job Address/Location °T �UT C o ,V/— <br /> Owner Ro AX riAAddress 30 9nac- <br /> 13 SEPTIC TANK ❑ CESSPOOL ®'LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br />[ IR PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 1 <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. FY., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> i <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r and regulations of the San 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 ❑ Ju+y 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> D TE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY <br /> OTHER <br /> OTHER 1 <br /> tx <br /> Received 6y Date - Receipt No. Permit No. 'Issuanc6 Date Mailed Delivered f <br /> j ---APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />