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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> Y. - (For Non-Transferable, Revocable, and Suspendable) <br /> r ENVIRONMENTAL HEALTH PERMIT SEPTAGE A <br /> LIQUID WASTE <br /> Application i ere4y ma a to car n business i the jurisdictional area of the Sa Joaquin Local Health trict <br /> .y Business Na DBA) �` C/E- �� Address 7� <br /> r <br /> z Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �F.1 _ !• Emergency Telephone No. <br /> Contractor Licence No. <br /> j L Applicants Name (Print, Title Date <br /> Please check Applicable Category (1-7)and Fill in the Requi ed Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> i For July 1, June 30, 19 Disposal Sites W <br /> I' Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licznse-Renewal'No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD } <br /> For July 1, June 30, 19 ss <br /> No. of Vehicles Stored J <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�ation Test Date/Time <br /> 4. SANITATION PERMIT. � ] <br /> Job Add r ss/Location 6 $ R - 4� '� 1 f- Ow <br /> Owners d Address /,f g � �r�Sea <br /> SEPTIC TANK ❑ CESSPOOL �l LL ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT r <br /> �ERMANENT ❑ TEMPORARY V� NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30,19 <br /> Type Construction Disposal Site N' <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 i <br /> Plant Location <br /> i <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> a <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> s <br /> I hereby certify that I have prepared this application and that the work will be done in accordadr4 it h San Joaquin County <br /> ordinances, state laws, and ru s and regulations of the San Joaquin Local Health District. `V <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USES ONLY 111y <br /> Fee IS Due: 11ANNUALLY ❑ PER UNIT L�PEH SITE ElEACH 11 J�u�f,.y�Received By January 31 El July 1 &Received By July 31 ' <br /> REMIT <br /> BILLING R&QITTA $ <br /> EASE EXPLANATION DATE ATE REMITTED AMOUNT DUE CHECKED 1 <br /> �( AMOUNT <br /> FEE Y t f <br /> LESS V <br /> PRORATION - <br /> PLUS I <br /> PENALTY ' <br /> OTHER <br /> OTHER <br /> . / 15 Cf[-7x7 ro <br /> Received by - -Date Receipt No.' Permit No. Issuance Date MailedDeliv ed <br /> APPLICANT_RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2005. STOCKTON,CA 95201 <br />