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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE, <br /> Application is eby made to a ryon mess i thju ' fictional area of the n Jo in Local Health Di <br /> Business Name ) Address <br /> aOwner Address ` <br /> Firm Partners, Addresses and Telephone Number <br /> a Business Telephone No. MSL /IQ- -- Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Na (Print) Title <br /> me Date <br /> Please,check Applicable Category (1-7) and fill in the Required I formation. <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C <br /> ♦.�.��� six a.�„.. <br /> For July 1, June 30, 19. Disposal Sites <br /> Description(Make/Yr., Color)4 "` - <br /> I Serial NodCAL. License No. CAL. License Renewal No. <br /> Capacity . `" '` � '' Gal., Weights & Measures No. <br /> tEquipment Parking;Address,- ' T <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATIONTEST-- ,• I x. o ... - <br /> R.S. or R.C.E. Name y _R.S. or R.C.E. No. <br /> Test LL tion ( _ t Test Date/Time <br /> 4. L� SANITATION PERMIT `` ' <br /> kJob Address/ cati - <br /> Owner. A ress <br /> ❑ SEPTIC TANK ❑ CESSPOOL I OKLACHING FIELD ❑ PACKAGE PLANT cJ <br /> ❑ PERMANENT ❑ TEMPORARY j ❑ NEW WREPAIR ❑ 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 /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name' Where Certified i <br /> Plant Location 44 <br /> i Plant Capacity j 4 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 /> l 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, and rulesd reg a I ns e n Joaquin Local HedItK District, <br /> APPLICANT'S SIGNATURE X <br /> ' FOR DEPARTMENT USE ONHollitV <br /> Feeds Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑f JALM e 4 ceived By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REM1TT41 $ REMIT <br /> BASE EXPLANATION DATE �A �E REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> i PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER f <br /> r <br /> Received by Date Receipt No. Permit No. Issu nce Date Mailed Delivered <br /> t APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 - <br />