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l 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 reby made to arty on busi ss in th j 'rd* 'onal area of the S oa uin Local Health District <br /> OBusiness Nam BA) Address 247 - <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone N-imhersor <br /> aBusiness Telephone No. Emergency Telephone No, <br /> Contractor Licence No. F, ) <br /> L Applicants Name (Print, Title Date r <br /> Please check Applicable Category (1-7) and Fill in the Required nformation S <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For;July,1,`• - i "';June 300'19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. ! CAL. License No. CAL. License Renewal No. <br /> Capacity` Gal., Weights & Measures No. <br /> I - <br /> EquipM6nt:Parking.Address Jt <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> f No. of Vehicles Stored .. T -ry _ ` " All - µ <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.ZrR .E. Name R.S.or R.C.E. No.on Test Date/Time <br /> ITATION PERMIT 7 Z <br /> Job Addre /Location <br /> Owner Address Z r <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ EACHING FIELD Eg< —[I_P_AGKAGE.P-L-AN.w -..,. <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW EPAIR I ❑ OTHER d.d <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site , <br /> No. of Units Equipment Storage/Cleaning Locatiionls)n + } <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 tl m <br /> 1 <br /> .� . ' L4 <br /> Operator Name Where CertifiedK <br /> Plant Location <br /> Plant Capacity N. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 � { + w <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> E I hereby certify that I have prepared this applicationd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules regulations ofAne S Joaquin Local Health District. <br /> I <br /> ! APPLICANT'S SIGNATURE X <br /> I <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 /> BILLING REMITTANCE $ <br /> SASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS r �\ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER f (� <br /> t N W <br /> Received by Date Receipt No. - Permit No. - Isbuande Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: r ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 .. <br />