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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 4 d r <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is here made to carry o bu iness in the urisdictIi'onal area of th n Joa n Local ealth Distri J <br /> 1n Business Name (DBA) �� �/G..� Address <br /> a Owner �� <br /> Address <br /> 0 Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Q7 Emergency Telephone No. <br /> Contractor Licence No. ZAj <br /> L Applicants Name (Print) �C' 4 �. Title �T`7 Date g <br /> Please check Applicable Category(1-7)and Fi11 in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) O <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse 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 st Date/Time <br /> 4. B ANITATION PERMIT J <br /> Job Address/Location gsadllw" '7,<A?,e_- <br /> Owner 7r Address <br /> 3 SEPTIC TANK ❑ CESSPOOL 2<EACHING FIELD C'SEEPAGE PIT ❑ PACKAGE PLANT <br /> 2 PERMANENT ❑ TEMPORARY BINEW ❑ 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 rb <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepared this application and tV the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, les an gulations he Sa Jodquin Local Health District. <br /> APPLICANT'S SIGNATURE <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE c � Lf's <br /> LESS ��1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 3 _i7 <br /> q Q <br /> Received by Date Receipt No. Permit No. 1psuancla Date Ma' d Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE„P.O.B 2009 STOCKTON.CAA 5201 . <br />