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T <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> �4 (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Nam (DBA) O Addr <br /> i Owner -� ~'5?—?/OSAddress 7 6 <br /> Firm Partners, Addresses and Telepho Numbers <br /> ILBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <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) CZ <br /> For July 1, June 30, 19 Disposal Sites ^- <br /> Description(Matte/Yr., Color) r <br /> Serial No, CAL. License No. CAL. Llcc,nse Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> I <br /> Equipment Parking Address i <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. X PERCOLATION TEST <br /> R.S. or R.C.E. Name G 5+e v e- 5 R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 1:1NEW ❑ REPAIR ❑ OTHER \J REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site C; <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 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> I 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 rules and regulations of the Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ( �1 <br /> 'S <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 /> REMIT <br /> BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED ; <br /> DATE DATE REMITTED AMOUNT I <br /> r O <br /> FEE �U <br /> LESS <br /> PRORATION <br /> PLUS <br /> 56 <br /> PENALTY c'7 <br /> OTHER <br /> OTHER p <br /> Received by Dale I Receipt No. Permit No. Issruance Date Mailed De vered <br /> E - APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 1 t+ <br />