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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 /> Applicatio hereby mad to carry on usine sin a juri 'ctional area of the Sa Joaqui Local Health Distri <br /> yBusiness Name B -Address �� ��7 '� <br /> z Owner Address �vcsL <br /> d <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 3�$ S O 5 Emergency Telephone No. <br /> d2-2—� Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) f <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) S <br /> Serial No. CAL. License No. CAL. License Renewal No. IJ <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 /> Testte'tion Test Date/Time <br /> 4. L`J SANITATION P f�IT <br /> Job Address/ ocatlon `K i'{' -eL' 1/110A;z 0'-" 7z <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPO 9'LEACHING FIELD ❑ 55 EPAGE PIT 13 PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY 1:1NEW W REPAIR ❑ OTHER <br /> S. ❑ 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 _ <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. <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, and rule and regulations of the n Joaquin 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 By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE �. S, 60 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER rs+� <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br />