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-.W. Applications Will Be'Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (Far Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application ' ere y ma to arty o sin the jurisdictional area of the 5a q Local ea h Dis t I' <br /> FBusiness N (DBA) Address Y <br /> a Owner Addr....; <br /> ess / <br /> Firm Partners, Addresses and Telephone Numbers <br /> a — or <br /> 1 Telephone No.—1 Emergency Telephone No. <br /> Contractor Licence No. O ` Z + <br /> L Applicants Name (Print) C.GA—' .5 ek Title —0-W-40— Date Z 4 <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) L <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) I <br /> I <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> _2.'�.11 PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stork <br /> No, of Chemical Toilets Stored ; <br /> 3. ❑ PERCOLATION TEST <br /> r <br /> R.S. or R;C.E. Name - R.S. or R.C.E. No. <br /> Test Location. = Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location G <br /> O�waer Address41-249* 61,E -� <br /> SEPTIC TANK CESSPOOL <br /> , LEACHING FIELD [A-EEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY WFEW ❑ 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) i <br /> 6. 1:1 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 hereby certify that I have pr d this appl' tion and that the work will be done in accordance with San Joaquin Countyi` <br /> ordinances, state laws, a ule nd regulat' an Joaquin Local Health District. I <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 /> I' BILLING REMlTTAN E REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECK�D <br /> e DATE DATE REMITTED AMOUNT <br /> FEE & <br /> LESS <br /> PRORATION I <br /> PLUS 99` <br /> PENALTY .I <br /> OTHER <br /> OTHER <br /> 4. <br /> Received by Date Receipt No. Permit No, - Issuance 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 />