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ApplicationsWill Be.Processed When Submitted Properly Completed. Be Sure To Sign The Application, 4 <br /> h' APPLICATION <br /> J! (For Non-Transferable, Revocable,and Suspendable) <br /> `' ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> J LIQUID WASTE <br /> Applicatio by mad car Joaquin in the jurisdictional area of the San Joan Lo 1 He th tr' <br /> rn Business N e DBA Addr Q <br /> t Owner J <br /> IAddress <br /> ff- <br /> 0 Firm Partners, Addresses and Te a hone Numbers <br /> ILBusiness Telephone No. 5 <br /> Contractor Licence No. Emergency Telephone No. <br /> L Applicants Name (Print) 1 <br /> Title Date—4;06--_��r` f <br /> Please check Appiicable Category (1-7)and Fill in the Required l formation <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. Licc &e 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 Addr /Location 33 3 3 <br /> Owner ' I Address .�13 <br /> s SEP IC TANK Ib ❑ CESSPO L LEACHING FIELD SEEPAGE PITACKAGE PLANT <br /> PERMANENT js ❑ TEMPORARY �r NEW ❑ REPAIR ❑ OTHER <br /> S. El CHEMICAL TOILETS For July 1, -June 30, 19 W <br /> Type Construction 1 Disposal Site <br /> i <br /> No. of Units Equipment Storage/Cleaning Location(s) Y <br /> B. ❑ PACKAGE TREATMENT PLANT ForjJuly 1, -June 3Q, 19 t <br /> Operator Name I <br /> Plant Location <br /> Where Certified <br /> , <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19_ ��4 <br /> SIZE: ❑ Less Tl an 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work willbe done in accordance with San Joaquin County <br /> ordinances, state laws, a and regulatio s of the n Joaquin Local Health District. <br /> '' t l( F <br /> APPLICANT'S SIGNATURE X <br /> I, <br /> I� FOR DEPARTMENT USE ONLY <br /> Fee IS Dile: 11 ANNUALLY ❑ PER UNIT, ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED a <br /> AMOUNT <br /> FEE I' <br /> LESS <br /> PRORATION <br /> PLUS r <br /> PENALTY" !•— �-n/ <br /> OTHER <br /> OTHER i <br /> II <br /> Received by j Date <br /> Receipt No. Issua ce Date <br /> �. P Permit Na Mailed Delivered a <br /> APPLICANT—RETURN ALL COPIES TO: .ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.14A2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95• <br /> it <br />