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App1iraatlons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applicafion'' - <br /> APPLICATION <br /> ��. (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> ' LIQUID WASTE <br /> Applicatio,la,iispereby made to carry o business in the jurisdictional area of the San Joaquin Local Heal h District <br /> y 01 <br /> Business Name B ) Address ! <br /> aOwner Address ' <br /> u Firm Partners, Addresses and Telephone Numbers + <br /> aBusiness Telephone No. ill �3� 9 Emergency Telephone No. <br /> Contractor Licence No, y- i <br /> L Applicants Name (Print) E' Title C�W_2A Q4l,>Ille,19 Date `l <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 J,u_ly 1, June 30, 19 j Disposal Sites <br /> f I <br /> Description(Make/Yr., Color) <br /> Serial No. CAL.. License No. CAL. License Renewal No. <br /> 4 � <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address + <br /> 2. ❑ PUMPER YARD <br /> ki <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored �. <br /> No. of Chemical Toilets Stored 1 ' <br /> 3, ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S.or R.C.E. No. <br /> Test Location i Test Date/Time <br /> 4. !q SANITATION PERMIT <br /> Job Address/L ation l eX' ! t "� <br /> `� <br /> Owner T Address ` <br /> ❑•SEPTIC TANK 1:1CES POOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT 4 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER 41 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 41 <br /> k <br /> Type Construction Disposal Site 1 <br /> No. of Units, Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> I Where Certified �I+I <br /> Operator Name <br /> Plant Location I ` <br /> Plant Capacity I 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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I <br /> .ordinances, state laws, a ul nd regulations of th an Joa n Local Health District. 1 <br /> I <br /> APPLICANT'S SIGNATURE X <br /> i FOR DEPARTMENT USE ONLY y <br /> Fee Is Due: 11-ANNUALLYM1� ❑ PER UNIT '❑ PER SITE ❑ EACH ❑ January 1 &Receive By January 31 ❑ July 7 &Received By July 31 <br /> REMIT <br /> - BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATEDATE �REMITTED AMOUNT_ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 00, <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date 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 95201 <br /> ai <br />