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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION i! , <br /> (For Nan-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE y <br /> Applicati Is hheereby de to c rry on buss s In the jure Ictional area of the San Joaquinl�Gal H alt Di ri�I <br /> v;Business Name (DB ) �/ate `" � � Gy�� Address l �� r� '� <br /> a •wnerj^�j- C/4 Address <br /> J Firm Partners, Addresses and Telephone Numbers v <br /> CL Business Telephone No. Emergency Telephone No. s <br /> Contractor Licence No. - <br /> LApplicants Name (Print) Title;k 15 7.1 Date r —mss <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. C3 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites !I. <br /> Description(Make/Yr., Calor) <br /> Serial No. CAL. License No. it CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address I i <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored II <br /> No. of Chemical Toilets Stored li <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. �V <br /> Test Location Test Date/Time 'j Jar <br /> 4. XSANITATION PERMIT ' <br /> Job Addre /Location <br /> Owner W 0MI151045 Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT' ❑ PACKAGE PLAT <br /> E)XPERMANENT ❑ TEMPORARY ❑ NEW 3rREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 g} <br /> Type Construction Disposal Site I 1 <br /> No. of Units Equipment Storage/Cleaning Location(s) 'I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 l # <br /> Operator Name i� 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 h ared this applicatio and that the work will be done in accordance with San Joaquin County # <br /> ordinances, state law , and and reg ul tions the Sa2fJoaquin Local 9 Health District. <br /> APPLICANT'S SIGNATURE X <br /> '. FOR EPA TMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January,1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> *, it REMIT L <br /> ' BILLING REMITTANCE �$ AMOUNT DUE CHECKED <br /> BASE EXPLANATION ' 1 <br /> DATE DATE fl REMITTED AMOUNT <br /> FEE <br /> LESS ; r <br /> PRORATION <br /> I <br /> PLUS !� <br /> PENALTY T <br />> OTHER t z <br /> OTHER _- � r• } <br /> Received by i�Date __ Receipt No. Permit No. Is uan Date Mailed Delivered <br /> !� r` <br /> APPLICANT—RETURN ALL COPIES T6 ENTAIL,HEALTH PERMIT/SERVICES I 1601 E.HAZELTON AVE.,P.O..Box 2009 P STOCKTON,.CA 95201` '' <br />