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y 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 i <br /> LIQUID WASTE <br /> Applicati is here made to c rry on busi in a jurisdictional area of the an Joa in Local Health District <br /> ,Business Name (DBA) Address T4 4yfz� <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and T II hone Numbers <br /> a Business Teiephone No. �ti tj 0 7 Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> JL- <br /> Applicants Name(Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <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. Licc,,se Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time pd <br /> 4. Q SANITATION PERMIT <br /> Job Addr ss/Location 054 4%AaiigA 90f::,5 <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL 9 LEACHING FIELD M SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 10 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> C4 <br /> Type Construction Disposal Site . <br /> No. of Units Equipment Storage/Cleaning Location(s) 5 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. 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 /> 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 r les and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X � -z� , <br /> �• 1 <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS 5 <br /> PRORATION <br /> J <br /> PLUS <br /> PENALTY <br /> OTHER <br /> P <br /> OTHER <br /> R su n <br /> Received by Date. Receipt No Permit No. Isce Date Mailed Delivered �!-f <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 115201 — <br />