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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> - ,F APPLICATION <br /> k /J (For.Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made,o carry on business in the jurisdictional area of the San Joaquin Local Health Distr' t, <br /> rn Business Name (DBA) A��F� _)_ 2 � >�fZ�>C— Address_�J <br /> z Owner <br /> a Address l <br /> J Firm Partners, Addresses and Tel hone Numbers <br /> CIL Business Telephone Na _q76, Emergency Telephone No. <br /> Contractor Licence No. <br /> IApplicants Name (Print) Date✓1_� 11-^ Titl ' a <br /> Please check Applicable Category (1-7)an 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. J <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address i <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 " <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. V ' <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT ` <br /> Job Address/Location - ? `���� �A1 <br /> Owner Address <br /> gS PTIC TANK [3 CESSPOOL OEl FIELD u SFEPAGE PIT PACKAGE PLANT t <br /> L� P5ERMANENT ❑ TEMPORARY 0-NEW ❑ REPAIR ❑ OTHER i <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 , <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) N. <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 �� <br /> Operator Name Where Certified <br /> Plant Location <br /> - �r <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. i <br /> I hereby certify that I ha a repared this ap I' ion a that the ill be done in accordance with San Joaquin County <br /> ordinances, state laws les nd regu ions ooh n Joaquinocal Health District. <br /> a <br /> APPLICANT'S SIGNATURE <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 31 <br /> REMIT <br /> BILLING REMITTANCE s <br /> BRISE EXPLANATION DATE DATE " REMITTED AMOUNT DUE CHECKED i <br /> FEE \ 1 AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS I <br /> ' PENALTY . 'I <br /> OTHER /s <br /> .. OTHER I <br /> Received by Date Receipt No. Permit No, Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Boa 2009 STOCKTON,CA 95201 <br /> I <br />