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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 /> r Application is hereby made to carry on b siness in the jurisdictional area of the San�quin Local Health District _ <br /> y Business Name (DBA) Address Q t !}� C <br /> 1 a Ownerf�, �i � � Address <br /> J Firm Partners,Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No, 1 <br /> LApplicants 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) f j <br /> Serial No. CAL. License No. CAL. License Renewal No. ; <br /> Capacity Gal., Weights & Measures No. i <br /> I Equipment Parking Address <br /> 4 <br /> 2. ❑ PUMPER YARD' <br /> For July 1, June 30, 19 ' <br /> No. Of Vehicles Stored?"' <br /> .No. of Chemical Toilets Stored — g. <br /> 3. ❑ PERCOLATION.TEST <br /> R.S. or R.C.E. Name <br /> R.S. or R.C.E. No. <br /> Test Location I— _Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location` `� �1. 'rte C <br /> OO�wner Address a <br /> { yySne�tPTIC TANK ❑ CESSPOOL I ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT � <br /> f ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑OTHER r <br /> 5. ❑ CHEMICAL TOILETS—For'July'1?-June 30, 19 3 ,CA <br /> Type Construction 1 Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) f <br /> 6. ❑ PACKAGE TREATMENT PLANT jiFor July 1, -June 30, 19 s <br /> Operator Name r Where Certified <br /> Plant Location <br /> Plant Capacity a L 71 No. Units Served F <br /> 7. ❑ LAUNDRY For July`1, -'June 30,`19 : ! <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ! ` <br /> i <br /> I hereby certify that I have prepared t is application and that the work will be done in accordance lth� ui1n�lounty <br /> ordinances' <br /> state laws, and rules an eq!110ons of t San Joaquin Local-Health District. <br /> i <br /> APPLICANT'S SIGNATURE X <br /> F _ <br /> ( FOR DEPARTMENT USE ONLY <br /> ti <br /> Fee Is--DiJE: ❑ ANNUALLY ❑ PER UNIT- ❑ PER SITE © EACH ❑ January 1 8 Received By January 31 ❑ July 1 &.Received By July 31 1 <br /> REMIT sd!' <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED '1'c AMOUNT F <br /> FEE <br /> LESS * <br /> PRORATION f f <br /> I PLUS <br /> PENALTY + F' <br /> OTHER F <br /> OTHER <br /> ►D�.� 5 [a is 11-6 M <br /> Received by - Date Receipt No. Permit No Istuaricd Date -Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SEAVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />