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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 /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,FBusiness Name (DBA) 4 . L �� f �� Address O, 7 <br /> aOwner Address `EZ ` <br /> J Firm Partners, Addresses and Telephonne� umberss ! <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. /► <br /> Applicants Name (Print) -�c � Title <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) I <br /> Serial No. CAL: License No. CAL.'Licc:-ce 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 /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT "?7�, w <br /> Job Address/Location ✓/ <br /> Owner s o 5 /� Address 1 .6 iAD&5. �-144 <br /> Com}SEPTIC TANK ❑ CESSPOOL R^CEACHING FIELD ❑ -SEEPAGE PIT- ❑ PACKAGE PLANT T- <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ 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) <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., 0 More Than 1,000 Sq. Ft. - ti <br /> ❑ DRY CLEANING, Chemicals Used/Ampunt/Mo. <br /> i <br /> T Y <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, anddrules and r gulati of the San Joaquin Local Health District. <br /> APPLICANT'S SIG ATURE X JAI' <br /> 0�71 J" b?,b7 <br /> FORD PARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ JWy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuance Data Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />