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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 /> s Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District _ <br /> N Business Name (DBA} ,es! - �c1 G L C'� Address <br /> z Owner Address <br /> a <br /> j Firm Partners, Addresses and Telephone Numbers r--� <br /> aBusiness Telephone No. 6 _ Emergency Telephone No, <br /> Contractor Licence No. ,�� 2- ' <br /> LApplicants Name (Print) li 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, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No., CAL. Licc^se 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 /> Name R.S. or.R.C.E. No. <br /> Test Location Test•Date/Ti me <br /> r`--4:--11-SANITATION PERMIT - - - <br /> j Job Address/Location <br /> Owner � �� Address <br /> Q <br /> / 11 �-- <br /> SEPTIC TANK CESSPOOL Ld!CtACHI"NG FIELD. ❑-SEEPAGE PIT— PACKAGE PLANT <br /> ❑ PERMANENT ❑TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER a <br /> 5. ❑ CHEMICAL TOILETS _For July 1, -June 30, 19,— <br /> . f <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 /> PlantLocation �c r <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 /> ,V ❑ DRY CLEANING, Chemicals Used/Amount/Mo. -. <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 regul ions f the S Joaquin Local Health Distract. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July I &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> V_ PRORATION <br /> PLUS .- <br /> `PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. lasuahce Dafte Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />