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messedWhen Submitted Properly Completed. BeSureTo SignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> f ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applic tion is hereb ade a on busine n the j ri ic�ti�onal area of t 5a quin Local Health District---�� t <br /> iness Name (DBA) 05 Address�6 ILA �_.f C -,` kT! <br /> wner_L� Address <br /> J Firm Partners, Addresses anTelephonelNumbers <br /> E Business Telephone No. ta -.1 Emergency Telephone No. <br /> �. <br /> Contractor Licence No. _ <br /> w � r <br /> n <br /> 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. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. ) <br /> Equipment Parking Address IN <br /> 2. ❑ PUMPER YARD �f <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored _ <br /> No. of Chemical Toilets Stared <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. 11 SANITATION PE ' <br /> Job Address/Locatio '. ' <br /> n % <br /> Owner Address r <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ EEPAG� ❑PIT PACKAG PLANT <br /> ❑ PERMANENT 1:1 TEMPORARY u NEW REPAIR ❑ OTHER <br /> 5:-11 CHEMICAL TOILETS For July 1, -June 30, 19 (.a) <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 <br /> hereby certify that I have prepared 9kis application and that the work will be done in accordance with San Joaquin County <br /> ordinances, stat d rules and fegNlafioK o th an J quin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EAGH ❑ January 1 R Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> yy `` AMOUNT <br /> `A <br /> FEE r�s, <br /> LESS <br /> PRORATION <br /> PLUS C <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 <br /> Received by Date Receipt No- Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />