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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r ` <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio h reby mad o car on busi s in the jurisdictional area of the San Joaquin Loc Healt Dis Ict <br /> FBusiness m (DBA) Address D <br /> a Owner Address Q <br /> r J Firm Partners, Addresses and Teleph ne Numbers 1 <br /> aBusiness Telephone No. o Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) ... Title _ Date X07 <br /> I Please check Applicable Category (1-7) and Fill in the Requk4d Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> M 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 /> i <br /> For July 1, June 30, 19 f, <br /> °No. of Vehicles Stored t. <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. 0 SANITATION PERMIT I <br /> Job Addr s/Location <br /> Owner �01 <br /> Address �dZ :- w-1 <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT "11:11CKA PLANT N <br /> X PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> S. ❑. 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 I 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 /> r <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state law, rules and rreegula ons of thigSan Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Grf✓ <br /> - <br /> . .� x ,-,FOR DEPARTMENT USE ONLY <br /> Fee Is Duel.❑ ANNUALLY ❑ PER DNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS /�I y <br /> PRORATION a J Y <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> 10 <br /> OTHER <br /> �'50d C?3-- <br /> Received E <br /> } 1 <br /> by- Date Receipt No. Permit No. I suanc Date Mailed Delivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,.P.O.Box 2009 STOCKTON,CA 952.0.1 <br />