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Appticatlons will tse rrocessea when Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Redoeeblo,And Suspendable) SEPTAC';' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the Jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) Address <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Q. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) r+ �!� 1,� Title _ Date (3'gV <br /> Please check Applicable Category (1-7)and Fill In the Required Information <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 No. _ CAL. License No. CAL. License Renewal No. <br /> Capacity _. Gal., Weights & Measures No. <br /> Equipment Parking Addresses �A� <br /> 2. ❑ PUMPER YARD �fZ <br /> For July 1, 1 June 30, 19 _ <br /> No. of Vehicles Stored <br /> o4j <br /> No.�ofChCh��ical Toilets Stored 00 <br /> 3. • PERCOLATION TEST �O� <br /> R.S. or R.C.E. Name �1J ►�tPf1/�12�JJ R.S. or R.C.E. No. q Z� <br /> Test Location —Wi�ii gyp&*' 'P�sr� Test Date/Time ywLl T �y� O <br /> 4. ❑ SANITATION PERMIT ,v <br /> Job Address/Location 1� <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ 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 t, -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 /> t. <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County <br /> ordinances,state lawsl r les a d r ations�pi jhe San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONL <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 ✓1 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE ; REMIT <br /> BASE �EXPLA ATIO DATE DATE EMITTED AMOUNT DUE CHECKED <br /> !'/ ,,,/ q'Y 7 c 1 ,�� AMOUNT <br /> FEE lvt4•� �Vl. —lOr 7H34z' 04�� ,9-0 O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY O 2- <br /> OTHER <br /> OTHER <br /> Rec ed by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />