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Applicans Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the an Joaquin Local Health District <br /> /� Address rz, <br /> y Business Name (DBA) � /E — <br /> aOwner Address t <br /> U Firm Partners, Addresses and Telephone Numbers <br /> M Business Telephone No. Emergency Telephone No. 4 <br /> Contractor Licence No. 3�3 <br /> Applicants Name (Print) <br /> Title Earxwrla-7cQ — Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) c f <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Lice Ise Renewal Na. j <br /> l <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> I <br /> Test Location Test Date/Time f <br /> 4. 'SSANITATION PERMIT <br /> Job Addres /Location / 5 a -5 , <br /> Owner - 7 D Address <br /> 1:1SEPTIC TANK 11 CESSPOOL OLEAGHING FIELD ETSEEPAGE PIT ❑ PACKAGE PLANT <br /> ��PERMANENT ❑ TEMPORARY ❑ NEW O'REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 /> I 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, a rules and gulations the Sa Joagyin 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 January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTA E $ AMOUNT DUE CHECKED <br /> DATE DAT R MITTEO AMOUNT <br /> FEE S� ` <br /> LESS <br /> 1 PRORATION <br /> I PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1� Received'by -Date Receipt No. Permit No. - I suance a Mailed Delivered <br /> ` APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601,E..HAZEL .,P.O.BOY 2009 STOCKTON,CA 95201 <br />