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j Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. k <br /> -�-j" APPLICATION <br /> 4 (For Non-Transferable, Revocable, and Suspendable) <br /> I ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> r <br /> Ap7plicatioqk's hereby ade to carryon us' ess in the jurisdictional area of the n Jo u n Local Health Districta. <br /> Business a e (DBA) Ol Address_ �'� <br /> z Owner G L Add-Less <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone Na. '-�� Emergency Telephone No. <br /> R a Contractor Licence No. <br /> LApplicants Name (Print) �� Title a�?/Llct Date 9' .zV� <br /> I 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 it Disposal Sites <br /> E Description(Make/Yr., Color) <br /> f Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. G4 <br /> Equipment Parking Address <br /> 2. Q PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> F 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time <br /> 4. Q'SANITATION PERMIT /f <br /> Job Address/ cationof <br /> Owner Zij&,11 Address �� �• — `� <br /> V'SEPTIC TANK ❑ CESSPOOL t LEACHING FIELD Q-tEEPAGE PIT ❑ PACKAGE PLANT a <br /> 92 PERMANENT ❑ TEMPORARY- i 01<EW ❑.REPAIR ❑ OTHER G' <br /> 4 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 U <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 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft:, ❑ More Than 1,000 Sq. Ft. <br /> © DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Y y <br /> I. <br /> I hereby certify that I have pr ared this Ii ation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an es and re t. s f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> k <br /> L FOR DEPARTMENT USE ONLY Ari <br /> �f <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Fi.4tp, January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTAN $ <br /> BASE EXPLANATION DATE DATE AMOUNT DUE CHECKED <br /> EMITTED <br /> . AMOUNT -- <br /> FEE �c' <br /> I - <br /> k LESS <br /> PRORATION <br /> I' PLUS - <br /> PENALTY <br /> OTHER <br /> t <br /> OTHER t <br /> :Received by Date, LL Receipt No. ,-�, Permit No. issuance Dat Mailed Delivered <br /> �APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTOH AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />