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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) SEPTAG <br /> ENVIRONMENTAL HEAL-TH;,PERMIT , <br /> LIQUID WASTE <br /> Application ' er y mad car on business in.the,jurisdictional area of the San Joaquin Local Health istr c <br /> �;Business Name BA) ! t R <br /> ."Address <br /> z Owner. . T w _ <br /> a Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business:Telephone No: �. ✓` dC. <br /> a _ Emergency Telephone No. <br /> Contractor Licence No. '" Y <br /> Applicants Name (Print) _ ~ ..•TitiISO <br /> e Date <br /> Please check Applicable Category (1-7) and Fill In the Required-Information _ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, W :June 30,,-19 - P-Disposal Sites f <br /> Description(Make/Yr., Calor) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity g '}Masures No.Gal., Wei" ht` 1 <br /> Equipment Parking Address.. <br /> 2. ❑ PUMPER YARD ` <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored s { <br /> No. of Chemical Toilets Stored �? { <br /> S. ❑ PERCOLATION TEST t ' <br /> R.S. or R.C.E, Name . 4 R.S. or R.C.E. No. <br /> Test Location ` t Test'Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location <br /> Owner ddres,�ss// � <br /> C3 SEPTIC TANK XL�LEACHING.FIELD +•'•SEEPAGE PIT ET PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY _— , ; j REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,09 t <br /> Type Construction Disposal-Site t 'd <br /> k <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> b. ❑ 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 certify that I have prepars appl' tion at the rk will be done in accordance with San Joaquin County '+} <br /> ordinances, state laws, and rule egul ns e S Joaq Local H th District. <br /> APPLICANT'S SIGNATURE X <br /> <,- - FOR DEPARTMENT USE ONLY <br /> i <br /> Fee IS Due; ❑ ANNUALLY ❑ PER.UNIT 11 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> . _ BASE EXPLANATION (BILLING I. REMITTANCE AMOUNT DUE CHECKED'--"". t - GATE, }•- .j . .DATE - - 'REMITTEd - AMOUNT- ' <br /> i. <br /> FEE 5 } 1 C <br /> LESS - - <br /> PRORATION <br /> PLUS <br /> - <br /> 'PENALTY <br /> OTHER l _ <br /> Received b i <br /> y '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 95 <br />