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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ;¢ (For Non-Transferab(e,'Revocable,and Suspendable) / SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on�usiness in the jurisdictional area of the San-Joaquin Local Health District -I <br /> ,Business Name (DBA) Address <br /> r <br /> a Owner Address r <br /> 1 Firm Partners, Addresses and Telephone Numbers <br /> 4 Business Telephone No. Emergency Telephone No, <br /> Contractor Licence No. <br /> Applicants Name(Print) „�� Title , `��� Date $�` <br /> Please check Applicable Category (1-7)and Fill in the Required Information : o� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, = June 30; 19 =' - - Disposal Sites <br /> 1 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License 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 i { <br /> No. of Chemical Toilets Stored 11 <br /> 3. 13PERCOLATION TEST, <br /> R.S. or R.C.E. Name _ R.S. or R.C.E. No. 4' <br /> Test Location I Test Date/Time <br /> 4. ❑ SANITATION PERMIT, <br /> a € <br /> Job Address/Location---�.-I <br /> Owner —r, Address <br /> ®' SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑.rNEWREPAIR ❑ OTHER r <br /> 5. ❑ CHEMICAL TOILETS For July 1;N June.30, 19�' <br /> s <br /> �. __ <br /> Type Construction ,_ Didposai Site d <br /> No. of Units Equipment Storage/CleaningLocation(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19� I <br /> t <br /> r't x <br /> Operator Name ) `Where Certified E "" <br /> ' ., , <br /> Plant Location i 4 <br /> Plant Capacity f No. Units-Served A <br /> w , <br /> 7. ❑ LAUNDRY For July 1;-June 30, 1.9- <br /> SIZE: <br /> .9 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More-f an 1,000 Sq-. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> W <br /> . � <br /> r <br /> . .Y'a-r�.�F`S - ;�"^� '°.�y'.wTrti'�x+Yr/ll�.:•• ,lhrewn°w�M4MYr�='..M.rrw,ra-.�..w�.�. t - <br /> - <br /> t I hereby certify that I'have prepared this application and that`,the work will be-done in accordance with San oaquin County <br /> n ordinances, state laws, and rule p and r ulat of the San'Joaquin Local Health Districi:,;• r,. <br /> APP LICANT'S,SIGNATURE X t i <br /> I <br /> y 1 d <br /> I ti FOR DEPARTMENT USE ONLY ., <br /> FeeIs Due: ❑`ANNUALLY ❑ PER UNIT ❑ PER SITE 13 EAC 0anuary 1 eceived By January 31 ❑ July 1 &Received By July 35 <br /> I 1 - 11 _'A <br /> _ -BILLING NCE i f REMIT <br /> BASE EXPLANATION ! $6 AMOUNT DUE CHECKED <br /> + DAT AT <br /> FEE REMITTED <br /> ll <br /> AMOUNT <br /> LESS •' � # <br /> PRORATION — ---� <br /> PLUS <br /> PENALTY { <br /> OTHERkf <br /> OTHER <br /> .:. S7 /d Z <br /> deceived by _ Date Receipt No. Permit No. IsAuanc ate Mailed Delivered <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.Oboa 2009 STOCKTON,CA 85201 <br /> . <br />