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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION - <br /> (For Non-Transierable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LiQUID WASTE <br /> Application i eby made to ca ry n busine�s,in the juri di onaf area of thei Joa in Local Health Dis <br /> rn Business Nam BA) �(� Address <br /> I`_ <br /> Owner _ Address <br /> Firm Partners, Addresses and Telephone Numbe j <br /> aBusiness Telephone No. lc�cEmergency Telephone No. ! ' <br /> Contractor Licence No. <br />�Applicants Name (Print) M4,da Title Dated <br /> Please-check Applicable Category (1-7)and Fill in the Required formation <br /> 1. ❑ PUMPER-VEHICLE,PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,-19 ° Disposal Sites <br /> Description(Make/Yr., Color.) <br /> Serial Na' wti =+ CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address - ` 1k+t <br /> 2. ❑ PUMPER`YARD <br /> For July 1 June 30,`19'' A <br /> No. of Vehicles Stored i 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 Location Test Date/Time <br /> 4. El SANITATION PERMIT d <br /> G "a" of <br /> Job Address/Lo ation d— <br /> A <br /> Address fjc. yl <br /> EPTIC TANK ❑ CESSPOOLACHING FIELD ❑ SEEPAGE PIT 11 PACKAGE PLANT <br /> L PERMANENT ❑ TEMPORARY 2 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) f n { <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, i <br /> ❑ {CRY CLEANING, Chemicals Used/Amount/Mo. I t <br /> hereby certify that 1 have prepared this application and that the work willrbe done in accordance witiiSan Joaquin County <br /> ordinances, state laws, and rules and re ns of the San.-. qy[r Local Health District. <br /> APPLICANT'S SIGNATURE X a <br /> FOR DEPARTMENT USE ONLY i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 &Received By January ❑ July 1 &Received By July 31 . <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED _ AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE { <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY. <br /> OTHER <br /> OTHER y <br /> Received by Date Receipt No. Permit No. I uan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />