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Applications Will Be Processed When Submitted Properlycompletes tie sure toatgn 1nes%ppucarrun. <br /> APPLICATION <br /> (For Non-Transierable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carryon busin ss intoe'urisdictional area of th San JJoa uin ocal e�lth Distri , <br /> Business Name (DBA) Ad�dr�e�} � <br /> a Owner L E:�E \I�k k--T t� �-�-� - Address <br /> Firm Partners, Addressejaehphoe umbe sCL Business Telephone No � Emergency Telephone No. r_..t-�Contractor Licence No. <br /> dc <br /> Applicants Name (PrintTitle �- Y Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information k <br /> t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) + <br /> t <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc-nse 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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PE IT <br /> Job Ads/Locati i r <br /> Owner 01,A­�rr f]7 Z. ( E Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ EEPAGE PIT ❑ PACKAGE PLANT N <br /> 11 PERMANENT 13 TEMPORARY ❑ NEW *%PAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 x <br /> h <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. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certif have prepare his applicat' and that the.work will be done in accordance with San Joaquin County <br /> ordinances, state law , d rul Ind1r, <br /> gu do o t e Sa Joa n Local Health District. <br /> APPLICANT'S SIGNATUR <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 13 January 1 &Received By January 31 ❑ Juty 1 &Received By 1 <br /> IT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT CHECKED <br /> DATE DATE REMITTED AMO NT <br /> FEE q,-s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY I <br /> OTHER <br /> OTHER <br /> `7r `- — =0- 1 -y0 a6,4,�xK� 4& <br /> Received by f Date I Receipt No. Permit No, Issuance Date Mailed Delivered_ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />