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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 <br /> Application is berebypade to arry on business in the jurisdi 'onal area of the San Joaquin Local Health Distric <br /> OBusiness Name BA) - fi t Address Ie D 0-1- 7,67 -� <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Num ers <br /> aBusiness Telephone No. -3d F S% Q 5 _ Emergency Telephone No. - __� <br /> Contractor Licence No. 8 2Z� <br /> LApplicants Name (Print) Z Title .__....._.. Date �` r.`�d <br /> Oct <br /> Please check Applicable Category (1-7)and Fill in the Required I ormation. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <br /> Serial No. CAL. License No. CAL. Llcc'ISe Rerowal 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 /> b 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time J <br /> { 4. ❑ SANITATION PERMIT r� <br /> Job Address/Location — !v��© 1'Cl tJ t —2 <br /> Owner-_ e,ltl �.,�-=.Q��— Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ GY T ❑ PACKAGE PLANT <br /> �. ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ 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 /> Operator Name Where Certified <br /> Plant Location to <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 /> F � <br /> I hereby certify that I have prepared this application and that the work will be done in accordance.with San Joaquin County <br /> I ordinances, state laws, and rules an -regulations of the San oaq in Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> iI <br /> FOR DEPARTMENT USE QINfl„ ) <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH -- ❑ Januar Received By January 31 ❑ July 1 &Received By July 31 ,fes <br /> BILLING REM�T At 0 $ REMIT <br /> BASE EXPLANATION DATE REMITTED AMOUNT DUE CHECKED r <br /> AMOUNT <br /> Y <br /> FEE IS <br /> LESS L �7 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - J <br /> P r <br /> Received by Date ReceJipYNa. Permit No. Issuaride Date` Mailed Delivered ' <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 ! <br /> Jr <br />