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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 /> i! ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> ' LIQUID WASTE <br /> I Application' 0. y mad o carryon uslness in the jurisdictional area of the San Joaquin Loc ealth District. <br /> ,�Business Na a DBA) ress Z20 _ --_ - <br /> aOwner_ r'? 1�% �/�' Address <br /> ' J Firm Partners, Addresses and Telephone Numbers <br /> E Business Telephone No. _. !L--4'l5-- Emergency Telephone No. <br /> Contractor Licence No. <br /> IL Applicants Name (Print) r' X_ Title �� � Date <br /> i Please check Applicable Category"(1-7) and Fill in the Required Information <br /> f 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) "ti4 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) I 1 <br /> Serial No. " CAL. License No. CAL. Licznse Renewal No. <br /> Capacity II Gal., Weights &Measures No. <br /> Equipment Parking AddressVV <br /> -- - <br /> 2. ❑ PUMPER YARD <br /> I For July 1, June 30, 19 <br /> i No. of Vehicles Stored li <br /> No. of Chemical Toilets Stored li <br /> 1 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> f Test Location Test Date/Time <br /> j 4,XZSANITATION PERMIT II <br /> I Job Address/LocaS on CI <br /> I � <br /> Owner l Address <br /> ❑ SEPTIC TA © CE5 POOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT O <br /> RMANENT ❑ TEMPORARY ;d-NEW `9-R€PAIR ,OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 4, <br /> Type Construction Disposal Site <br /> j No. of Units .; Equipment Storage/Cleaning Location(s) <br /> 6. El PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> ' Operator Name I Where Certified <br /> Plant Location II <br /> Plant Capacity II No. Units Served eft <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 it <br /> it <br /> I hereby certify that I;-have epa a h' appl ation nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a ru gulati s of a San quin Local Health District. <br /> APPLICANT'S SIGNATURE X / <br /> ;I <br /> i. <br /> I <br /> II FOR DEPARTMENT USE ONLY <br /> II { <br /> Fee Is Due: ❑ ANNUALLY h ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ July 1 &Received By July 31 <br /> 'I BILLING -REMITTANCE $ REMIT <br /> ' BASEl EXPLANATION DATE DATE REMITTED AMOUNT DUE - CHECKED <br /> ! AMOUNT <br /> Ct FEE <br /> t LESS Il <br /> ffff PRORATION !I <br /> PLUS it G <br /> r PENALTY ! `s <br /> I OTHER <br /> - OTHER <br /> •L 1 C� <br /> I Received by -Dater Receipt No. Permit No, Iss a to Mailed Delivered <br /> f APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ON AYE.,P.O.BoM 2009 STOCKTON,CA 85201- <br /> , <br />