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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 /> Application is r 6'y made to ca on business. the juris ictional area of theoaquin Local Health DistriclooO <br /> y Business Name A} `f Address � �� <br /> Owner ddress <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. d Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date 149 2- 7 <br /> Please check Applicable Category (1-7)and Fill in the Required Information I 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) _rI <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) 1 <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address I <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored 0 <br /> No. of Chemical Toilets Stored Q <br /> 3. ❑ PERCOLATION TEST <br /> or R.C.E. Uame a R.S. or R.C.E. No. <br /> Test Date/Time S42 <br /> ry <br /> 4. 13 SANITATION PERMIT I � <br /> Job Address Location _ d0 �/yt ,1,[RAP'o 3_� 0.- <br /> 0 <br /> LB Address <br /> SEPTIC TANK ❑ CESSPOOLACHING FIELD aSEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY �'T NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <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 a <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> O <br /> 1 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 rul nd regulations S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY /�(� <br /> Fee Is Due: 11 ANNUALLY [I PER UNIT El PER SITE 13 EACH ❑ January 1 &Receivedti anua 3 J ly 1 ived By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> A O T CHECKED <br /> DATE DATE EMITTE AMOUNT <br /> FEE � ys�' � C <br /> LESS 31 eeJ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> w <br /> Received by Date Receipt No. Per it No. ssuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br /> i <br />