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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 Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE f <br /> LIQUID WASTE <br /> Application is ereby made to rry on business in the jurisdictional area of the S Jo uin Local Health Distric p <br /> Business Name (DBA) ,- <br /> aOwner Add s <br /> Address <br /> r Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. e, <br /> Contractor Licence No. Z Z Emergency Telephone No. II <br /> Applicants Name,(Print)-, �e G <br /> Please check Applicable Category Title Date D } <br /> g ry(1-7) and Fill in the Required Inf rmation <br /> 1. ❑,PUMPER VEHICLE.PERMIT REGISTRATION(FOR EACH VEHICLE) Y <br /> For July 1, *June 30, 19 <br /> Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. ( )r� <br /> _ CAL. License No. - CAL: License Renewal No. <br /> Capacity Z �' �j� ` <br /> Gal., Weights & Measures No, 4 "` '"■` ►a i( <br /> Equipment Parking_Address �- Y I <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> .No. of Chemical Toilets Stored kms, <br /> 3. ❑ PERCOLATION TEST i r <br /> R.S. or R.C.E. Name <br /> i`.R.S dor R.C.E. No. <br /> Test L tion Test Date/Tirrie' I <br /> 4. EU SANITATION PERMIT <br /> Job Address/Location <br /> Owners Addr s c" +� <br /> El SEPTIC TANK ❑ CESSPOOL LEACHING FIELD GY -+� <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW PACKAGE PLANT <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ❑ REPAIR ❑ OTHER <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 _ s Where Certified <br /> Plant Location "� �Ila� <br /> Plant Capacity <br /> No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ' '`` I'd A <br /> SIZE: 11 Less Than 1,000 Sq. Ft., El More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and'that the work will be dome in accordance with <br /> San Joaquin County I <br /> ordinances, state laws, and rut nd regulations of a Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X t>✓ <br /> FOR DEPARTMENT USE ONLY I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> •� AMOUNT ' <br /> LESS V <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER i <br /> OTHER 1 <br /> t <br /> q� it <br /> Received by Date �" O 1 Ov <br /> Receipt No. Permit N. ssua ce <br /> APPLICANT—RETURN ALL COPIES TO: Date Mailed ' <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES Delivered ` <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 Al <br />