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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) i <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> r <br /> LIQUID WASTE <br /> Application iclgereby made to carry on b iness in the jur Ictional area of the SM Joaq 'n Local Health Distric <br /> yBusiness Name (D A) lib er Address - r-. V G 7 ° <br /> z Owner - Address <br /> a <br /> L) Firm Partners,Addresses and Telephone Numbers <br /> ILL Business Telephone No. C7 I e Emergency Telephone No. <br /> Contractor Licence No. Z� x— <br /> �Applicants Name (Print) Title Date 7— IlkCJ Q <br /> Please check Applicable Category (1-7)and Fill in the Required Information { <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> j Serial No. CAL. License No. CAL. License Rencwal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> h <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�1?,Lo ion Test Date/Time L <br /> 4. SANITATION PERMIT <br /> Job Add Location Z 3 5'�4 `� a gym` s <br /> Owner Address <br /> ❑ SEPTIC TANK E] CESSPOOL ❑ACHING FIELD C AGE PIT ❑ PACKAGE PLANT e� <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW IVREPAIR ❑ OTHER f <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s). . r <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 work will be done in accordanissith San Joaquin County <br /> ordinances, state laws,-and r=�dations th San oaquin Local Health District. <br /> i APPLICANT'S SIGNATURE X ' <br /> c <br /> FOR DEPARTMENT USE OVLFee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ anuaceived By January 31 ❑ July 1 &Received By July 37. <br /> REMIT <br /> BILLING REMIT .NCE $ <br /> BASE EXPLANATION DATE D REMITTED AMOUNT DUE CHECKED <br /> I AMOUNT <br /> FEE ,�j'{/5 <br /> p O <br /> LESS YYrr t <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> PO <br /> Received by4 - Date Receipt No Permit No, Issuance Date Mailed Delivered - <br /> [; APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/sERvlcEs - 1601 E.HAZELTON AYE.;P.O.Box,2009 STOCKTON,CA.95201 <br />