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- � - <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> AP �ATION �.:: <br /> (For Non-Transfle. Revocable, and Suspendable) <br /> ENVIRONMENTAL <br /> HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE _ <br /> Application is hereby-mad <br /> e to carry on business in the jurisdictional-area of the San Joaquin Local Health District 7 <br /> Business Name (DBA) C Address m �3 <br /> a Owner Address <br /> 1 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. Z$ <br /> d <br /> Applicants Name (Print) Ste' / Title _y5'f' _ Date !V— 11'-8 p <br /> Please check Applicable Category (1-7)and All in the Required Information <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> 1 <br /> Description(Make/Yr., Color) 4r <br /> Serial No. CAL. License No. CAL. License Renewal No. j <br /> Capacity Gal., Weights &Measures No. <br /> } <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 <br /> ,,,Lo�ion Test Date/Time <br /> 4. a SANITATION PERMIT <br /> Job Address/Location 2 <br /> Owner Address -+r _ <br /> �SEPTiC TANK ❑ CESSPOOL BLEACHING FIELD Z`!�EEPAGE PIT l❑"PACKAGE PLANT <br /> CTIPERMANENT ❑ TEMPORARY 91IEW El REPAIR ❑ OTHER <br /> 5, 11 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 N_o. 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. 1! <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Ma. <br /> F <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Y E <br /> ordinances, state laws, rules and ulation f the n Jo quirt Local Health District. <br /> APPLICANT'S SI EX <br /> Zell r <br /> ' FO DEP TMENT U ONLY <br /> Fee IS Due: 11 ANNUALLY ❑APER UNIT PER SITE EACH January 1 d&ReceiveBy,Januar <br /> 31 <br /> _ Y ❑ July 1 &Received By July 31 <br /> BASE - EXPLANATION BILLING REMITTANCE - $�� a REMIT <br /> • <br /> DAT EDATE - REMITTED AMOUNT DUE CHECKED <br /> Y F F AMOUNT <br /> FEE <br /> LESS AA 5 <br /> PRORATION <br /> PLUS f dr <br /> PENALTY <br /> OTHER <br /> OTHER _ - <br /> wo <br /> 1�'[ <br /> Received by -� - Date Receipt N. 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 95201. <br />