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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 i ereby madelo carry on 4usiness in the juris Ictional area of the San Joaquin Local Health District <br /> NBusiness Name BA) J - > Address / ` <br /> F <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numbe <br /> IL a Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print} - Title }�� _ Date <br /> Please check Applicable Category (1-7)and Fill in the Required I formation I <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. Liccase Renewal No. <br /> Capacity Gal., Weights-& Measures No. - - <br /> Equipment Parking Address <br /> j 2. ❑ PUMPER YARD <br /> i For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> f R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Dation Test Date/Time <br /> 4.-- L`J SANITATION PERMIT / fi _ <br /> Job Address/Location �a C�G�1�ct v 1.e.fEcs.�.�vl <br /> Owner '� Address 415 <br /> IVSEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> QYPERMANENT ❑ TEMPORARY ❑ NEW f ❑ REPAIR 11. 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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> v <br /> Plant Capacity No. Units Served <br /> I 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> 1 <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, and rules and re ul tions 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 ay July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �j AMOUNT <br /> FEE L4 5 CPN_. <br /> I LESS <br /> PRORATION 1 <br /> PLUS t <br /> a PENALTY <br /> f <br /> OTHER <br /> p - <br /> OTHER ' <br /> 11gl�dp �7 � <br /> Received by Date Receipt No. Permit Na, I suance Date Mailed Delivered <br /> k APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE_P.O.Box 2009 STOCKTON,CA 95201 . <br />.r I <br />