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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 R <br /> LIQUID WASTE <br /> Application i ereby made t carry o siness in the jur' fictional area of the San Joaquin Local Health District <br /> 1.11,Business Name (DBA) r Address es 76 � <br /> aOwner ddress - <br /> 4 J"Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. _3 46/Q S Emergency Telephone No. <br /> Contractor Licence No. L` <br /> me Pi <br /> _ <br /> Applicants Na (Print} Title Date "Z T'� 1 <br /> Please check Applicable Category (1-7)and Fill in the Required In ormation (n <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites (A <br /> Description(Make/Yr., Color) <br />' Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights t£Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 i <br /> No. of Vehicles Stored 'I <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 LKo ation Test Date/Time <br /> 4. to SANITATION PERMIT <br /> Job Address/Locat" n Z 411 <br /> Address <br /> L.t SEPTIC TANK CESSPOOL ACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT p e <br /> ❑ PERMANENT 11 TEMPORARY 1�� <br /> NEW ❑❑ REPAIR ❑ OTHERN <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 i <br /> Type Construction f 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., 0!More Than 1,000 Sq. Ft. � <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br />' I <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 ruI and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY j <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 y 1 &Received By July 31 <br /> REMIT <br /> - $ <br /> BASE EXPLANATION BILLING REMITTANCE DATE DATE REMITAD ArleOUIJIUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY r - <br /> I <br /> OTHER ► <br /> OTHER <br /> 1 <br /> Received by Dale i Receipt No. - Permit No. Vssuance ate I Mailed -Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON'AVE.,P.O.Box 2009 - STOCKTON,CA 95201 <br />