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f, 4. Applications`Will Be Processed When Submitted Properly Completed. Be SureTo SignTheApphcauon. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> i; ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE y� <br /> Application i hereby mad to carry on business in the juri ictional area of the Sa oaquin Local Health District I <br /> d - r <br /> OBusiness Name BA) Address i <br /> z Owner Address <br /> Q <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL a Business Telephone No. r C� Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Require . Information <br /> cow <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) A <br /> For July 1, June 30, 19 11 Disposal Sites <br /> Description(Make/Yr., Color) J <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> i Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ POMPER YARD <br /> For July 1, y^ June'30; '9 ' �- <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> is R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> i <br /> 4. C1 SANITATION PERMIT <br /> Job Addre /Lotion <br /> Owner M- <br /> Address e 8'1 D <br /> 11 SEPTIC TANK I- <br /> CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> i <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW a REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction ii Disposal Site <br /> 4 No. of Units Equipment Storage/Cleaning Location(s) <br /> r 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> ` Operator Name <br /> Plant Location <br /> i Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> I SIZE: ❑ Less Than 1,000 Sq,?Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> N' <br /> k I hereby certify that II have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i ordinances, state laws, and r s and regulations o S n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X //} <br /> l li' <br /> II <br /> (- li FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I0.. <br /> FEE 91 s <br /> ��`' <br /> LESS <br /> + PRORATION <br /> PLUS II <br /> PENALTY @ <br /> OTHER <br /> ,p <br /> 4 OTHER <br /> Received by Date Receipt No Permit No. IssuanceDate -Mailed - Del ive ed ; <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT ERVICES - r 1601 E:HAZELTON AVE.,.P.O.Box 2009 STOCKTON,CA 95201 <br /> 77 - ' <br /> y <br />