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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 /> Applica is herglTy made to car business i the jurisdictional area of thJoaq m Local Health/District <br /> Business Name (DBA) f.t= ..____ - ��r; - Address_ San 14M - :37VIV _<,In F <br /> z Owner Address <br /> Q <br /> J Firm Partners, Addresses and Tel hone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <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. Liccnse 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 <br /> Job Address// cation t1 �rLpwf1 � ' <br /> Owner tZ_ RIl A),—.iL1)/1U-t Address <br /> .SEPTIC TANK ❑ CESSPOOL .9 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> -PKPERMANENT ❑ TEMPORARY ❑ NEW I< REPAIR 0<OTHER 4.<S-x to + (SE0 <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., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 hereby certify that I have prepared this application and that the workwl be done in accordance with San Joaquin County ' <br /> ordinances, state law , and rul�and �nsof the 5 in Lo Ith District. - <br /> APPLICANT'S SIGNATURE X r <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEES <br /> LESS <br /> PRORATION ' <br /> r <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issu nce Date Ma ed elivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AYE., . . ox 20oo STOCKTON,CA 95201 <br />