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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati n is her by ade car on bush T r dlr hal area of the San Joa J ip L'g�al HealtDistrict � I <br /> Business N me (DBA) y Address /. (� <br /> Address <br /> za Owner-.,w��,_,�� - -; <br /> Firm Partners, Addresses and Telephone Numbers L <br /> _- �i G U Emergency Telephone No. <br /> a Business Telephone No. I <br /> a <br /> Contractor Licence No. /Applicants Name Name (Print) -^� Title � -T— Date 0 <br /> InL <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) CAL. Lic:.,se Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights & Measures No. <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. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. )4 SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR DkOTHER DxLmvot.tiZLOf..,y (y <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> f No. of Units Equipment Storage/Cleaning Location(s) <br /> f 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <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 /> M ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> VS- <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rules an realtion the Sa'n J uin Local Health District. <br /> I APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT <br /> PER SITE ❑ EACH- ❑ January 1 &Received By January 31 July 1 &ReceivedREMIT 31 <br /> k BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> t ��5 c <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS $ /� <br /> PENALTY <br /> [ OTHER <br /> OTHER <br /> `fi <br /> ate Receipt No. Permit No. Issuance ate Mailed Delivered <br /> _ Received by = <br /> f 1601 E.HAZELTO E.,P.O.Box 2009 STOCKTON,CA•9520t <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />