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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 h reby made to carry on business in the jurisdictional area of the S oaquin Local Health District <br /> NBusiness Name (DBA)// _ Address dcz <br /> QOwner_. C. f�c. ��� / _ Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No, <br /> Contractor Licence No. ^ <br /> L Applicants Name (Print) Title Date y - <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. 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 r,fl <br /> No. of Chemical Toilets Stored Y <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. _ <br /> Test Location Fest Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location -dzJISCA 6{�e= - l- <br /> 1�' <br /> Owner �]��. � C Address DU K F— <br /> U�-S'EPTIC TANK ❑ CESSPOOL — 0-1 ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Q <br /> Type Construction Disposal Site C <br /> No. of Units Equipment Storage/Cleaning Location(s) '0' <br /> CA <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 f% <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 /> 'r. <br /> 1 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 re ationf the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE I <br /> x <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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE i- <br /> LESS <br /> PRORATION ( / <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - '- - <br /> Rece' by Date I Receipt No. Permit No. ssuance Date Mailed Delivered I <br /> LtCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 / <br />