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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 /> Application is her, y made to carry on business in the jurisdictional area of the San Joa uin Local Health District G �� <br /> w Business Name (DBA) fes, A? C -A> Address �4 D .9 k T C�'n/_'v �A <br /> a Owner S 14 ^ L' Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. 7 Emergency Telephone No. <br /> Contractor Licence No. G <br /> L Applicants Name (Print) A , 4z"'i C'#,4 <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) d <br /> For July 1, June 30, 19 Disposal Sites } <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Lic_znse 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 Stared <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. A SANITATION PERMIT �} <br /> Job Address/Locati n C7r <br /> Owner '1 ' <br /> Address <br /> SEPTIC TANK ❑ CESSPOOL` LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site — <br /> No. of Units Equipment Storage/Cleaning Location(s) _J <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 -� <br /> Operator Name Where Certified '421 <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 /> I hereby certify that I have prepared this application and t . the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a Tul a regulations of the J aquIn Local Health District. <br /> APPLICANT'S SIGNATURE X I��v <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE yS� `y y <br /> o r� <br /> LESS d <br /> PRORATION <br /> PLUS \ <br /> PENALTY <br /> OTHER �\o <br /> OTHER <br /> Received by pate Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AV .Box 2009 $TOCKTON,CA 95201 <br />