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Applications..' ill Be Processed When Submitted Properly Completed. BeSureToSignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> !I. <br /> LIQUID WASTE <br /> A licatio I he eb m e to car on b mess n jurisdictional area of the Sa oaquin Local Health Dis t <br /> PP dd Y ry <br /> ,F Business N e (DBA) , T� `II' � Address <br /> aOwner cC x �� ' Address 024 �— <br /> J Firm Partners, Addresses and Teleq�hone Numbers r oX <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. Q Sw 72 <br /> Applicants Name (Print) fEzE 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, -- — Disposal Sites �- <br /> Description(Make/Yr., Color) IM <br /> Serial No. CAL. License No. CAL. Liccrse Renewal No. <br /> Capacity ��I Gal., Weights & Measures No. <br /> Equipment Parking Address �M <br /> 2. ❑ PUMPER YARD II <br /> For July 1, June 30, 19 �• <br /> No. of Vehicles Stored .11; <br /> No. of Chemical Toilets Stored <br /> .3. ❑ PERCOLATION TEST � <br /> R.S. or R.C.E. Name I <br /> R.S. or R.C.E. No. <br /> Test Lo ation 'Ij! Test Date/Time - <br /> 4. L SANITATION PERMIT �f� y <br /> Job Addres Location d ?ZA <br /> II Oar c -- at <br /> Owner Address <br /> LN-ISEPTIC TANK ❑ CESSPOOL: LEACHING FIELD R--SEEPAGE PIT, ❑ PACKAGE PLANT <br /> U-PERMANENT ❑ TEMPOR'ARY M-NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS ForliI`Ju!y 1, -June 30, 19- <br /> Type <br /> 0, 19Type Construction 11 Disposal Site <br /> No. of Units If Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> k Operator Name �� Where Certified <br /> Plant Location <br /> Plant Capacity. No. Units Served <br /> 7. 11 LAUNDRY For July 1, -J,une 30,'l 9 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> k li <br /> is <br /> I . <br /> I hereby certify that I have prepared this pplication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws!�a and re ns f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I I� <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 ReceivedByJuly 3 <br /> T BILLING REMITTANCE $ AMOUNT DUE CHECK <br /> BASE" EXPLANATION DATE DATE REMITTED AMO <br /> FEE <br /> k LESS <br /> PRORATION <br /> PLUS �I <br /> PENALTY .II <br /> OTHER <br /> OTHER I� <br /> L <br /> 4 Mailed Delivered <br /> Received by Date Receipt No. Permit No. Issuance Date <br /> r APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Bo 9. STOCKTON A 9 201 r: <br />