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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> 1 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of th an Joa I n Local Health District <br /> Business Name (DBA {`ri i�S e'D it N%C C TV\C Address V -C3• So)4 76 7 <br /> z Owner �trle{f q6 r9 p Address YYl <br /> a <br /> Firm Partners, Addresses and Telep one Numbers <br /> aBusiness Telephone No. Q Emergency Telephone No. <br /> Contractor Licence No. Z ZCn <br /> Applicants Name (Print) Title , yiC rP Date <br /> Please check Applicable Ca ory(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 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 Location Test Date/Time <br /> 4. -SANITATION PERMIT <br /> Job Address/ ocati n U f t" e t W e, t Qo r i <br /> Owner Addr : <br /> C�S'SEPTIC.TANK ❑ CESSPOOL -" ACHING FIELD E EPAGE PIT ll PACKAGE PLANT <br /> 0-15ERMANENT ❑ TEMPORARY 0-14EW ❑ REPAIR ❑ OTHER �l I <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 b <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 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 /> 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 laws, rules and guI ions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT \ <br /> FEE 4 } <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY — <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issulance Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />