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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSign <br /> APPLICATION <br /> (For Non-Transferable, Revocable„and Suspenda.ble). SEPTAGE l <br /> sT. i <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQuIo-WASTE i A <br /> Application' ereby mad o carry,on business"in the jurisdictional area of the Sa oa L He th Dist 'c t <br /> Ad ess <br /> Business N e (DVA) <br /> ress <br /> a Owner <br /> Firm Partners, AdresSes and T I phone N m s Emergency Telephone No. <br /> a Business Telephone No. <br /> Contractor Licence No.. Q Title �/ Date <br /> Applicants'Na([ie`("Print} <br /> Please.check_Applicable Category {1-7)and Fill in the Required Infar allon <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For}J.uly 1,-- June 30, 19 Disposal Sites 9 <br /> DesOript.on,(Make/Yr., Color) CAL. License Renewal No. - <br /> Serial No CAL, License No. ` , <br /> Capacity-.' Gal.,Weights &Measures No. { <br /> Equipme4.Parking Address C <br /> 2. ❑ PUMPER YARD <br /> For July'1'1_ June 30, 19 - <br /> r_ <br /> No. of Vefiicles`Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.NO. <br /> R.S. or R.C.E'Name Test Date/Time <br /> Test Location <br /> 4. A SANITATION PERMIT <br /> Job Address/Jqacation i <br /> Owner Address <br /> ❑ CESSPOOL ❑ LEACHING FIELD AGE PIT , ,0 PACKAGE PLANT' <br /> �SEPTIC:TANK 11 REPAIR <br /> - ❑ OTHER <br /> PERMANENT <br /> E] TEMPORARY NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> j Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 34, 19 <br /> I Where Certified <br /> Operator Name I <br /> Plant Location ,1 <br /> No. Units"served _ <br /> Plant Capacity <br /> 7. 11LAUNDRY For July 1, -June 30, 19 <br /> ,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1 <br /> ( ❑ DRY CLEANING, Chemicals Used/Amount/Mo. j, t <br /> a lication and that the work will be done in accordance with San Joa u n County <br /> I hereby certify that I have prepared this pp <br /> ordinances, state laws, and r es knd regulati of the San Joaquin Local Health Distract. <br /> APPLICANT'S SIGNATURE X <br /> � - x <br /> FOR DEPARTMENT USE ONLY <br /> t <br /> ❑ ❑ EACH El January 1 8"Received By S <br /> PER UNIT PER SITE anuary 31 [1Suly 1 &Received By JOY 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ REMIT <br /> !. BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> k BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS I' ` <br /> PRORATION <br /> t i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> k OTHER <br /> Receipt No. Permit No. Issuance Date ed Delivered <br /> ll Received by Date1601 E.HAZELTON AVE.,AYEP.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—OF-rURN ALL COPIES TO: <br /> ° ENVIRONMENTAL HEALTH RMITtSERYICES - -� <br /> il, <br />