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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ,,:or Non-Transferable, Revocable, and Suspendamv) �( SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> LIQUID WASTE <br /> Applicati n is hereby made tQ,� r on busin s�in the rtdictional area of the S� Joaquin Local He th Istrict� <br /> H Business Name (DBA) _ �� L L � 1 f�E Address J CI r �� �1C'i <br /> aOwner L W ALS_h; Address <br /> Firm Partners, Addresses a94TPI hone Numb rs <br /> K Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) - Title �u _ i ate <br /> Please check Applicable Category (1-7) and Fill in the Required Information ) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) L <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. _ _ CAL. License 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 PERMIT _ <br /> Job Addre ocation � '61 <br /> Owner _ Address -- <br /> ArSEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY rR NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ 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 /> 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 ap lication and �at the work will be done in accordance with San Joaquin County <br /> ordinances, sta a laws, a d res an re uI ns ofi th S Oa in Local Health District. <br /> APPLICANT'S SIGNATURE X * i / - <br /> , <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT <br /> FEE Com/ <br /> LESS L <br /> PRORATION <br /> PLUS N 1 <br /> PENALTY <br /> OTHER > .. <br /> K7�t <br /> OTHER <br /> ( 3 <br /> Received by Date Receipt No. Permit No. -Issuance Date _ ailed Delivered <br /> APPLICANT—RETURN ALL COPIES 70' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />