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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. v <br /> APPLICATION <br /> • (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appli) ion heP ma a to ca ry n b lness in the jurisdictional area oft S J quin Local Health District <br /> �;Business Name DBA ,4 Q �_aLL�� Address <br /> aOwner Address <br /> Firm Partners, Addresses and Telgphone Numbers } <br /> a. Business Telephone No. u, L Emergency Telephone No. •r <br /> d Contractor Licence No, <br /> L Applicants Name (Print) AATitle -rl ,T�-r'Q�2 ._ Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 # Disposal Sites �1 <br /> Description(Make/Yr., Color) ` k <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> -'Capac'ity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> .2. ❑ PUMPER YARD 1 <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.0-E. Name R.S. or R.C.E. No. <br /> Test Lobation Test Date/Time <br /> 4. SANITATION PERMIT 1 <br /> Job Address Locationst � O 9- <br /> Owner �-�C i Address <br /> ,❑-,,SEPTIC TANK El CESSPOOL LEACHING FIELD SEEPAGE PIT El PACKAGE PLANT <br /> L— I <br /> PERMANENT ❑ TEMPORARY ❑ NEW B'REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �I <br /> Type Construction Disposal Site <br /> No. Ot Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 0�5 <br /> Operator Name # Where Certified <br /> Plant Location <br /> t Plant Capacity <br /> No. Units Served . <br /> 7. ElLAUNDRY 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 /> S. <br /> I hereby certify that I hav repared this application and that the `or will be done in accordance with San Joaquin County 1 <br /> ordinances, state laws, lbs-and..r Mations o- a San Joa n Loc I Health District. <br /> APPLICANT'S SIGNATURE. <br /> d <br /> S <br /> FOR DEPARTMENT USE ONLY. <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE Q-EACH ❑ January T'&Received By January 31 ❑ July i &Received By July 31 <br /> l BILLING ' REMITTANCE REMIT <br /> DATE I <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> _ .;, DATE -,REMITTED If <br /> ` AMOUNT I <br /> FEE <br /> a , <br /> LESS <br /> PRORATION ! <br /> PLUS <br /> PENALTY G <br /> c <br /> } OTHER - <br /> v <br />=� OTHER <br /> 3�S b )(0rn <br /> Received hY Date Receipt N. Permit No. -- issuance vaie Mailed: <br /> _ Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES ?` 1501 E.HAZELTON AVE.,P.O.eox 2009 STOCKTON,GA 952011-'- <br /> 2 <br /> 5201' �' <br />