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T T Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> m' ENVIRONMENTAL HEALTH PERMIT SEPTAGE t <br /> LIQUID WASTE <br /> Application is h by made to c rry on business in the jurisdi tional area of the San Joaquin Local Health irict <br /> N Business Name A) Address O�O 76 7 �- <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> 4 2—T <br /> Z� I <br /> Contractor Licence No. <br /> Applicants Name (Print} Title Date 7"24' <br /> Please check Applicable Category (1-7)and Fill in t4 Required information A <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) �! <br /> Serial No. CAL. License No. CAL, Lfccnse Renewal No. t <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. 6 <br /> Test Dation Test Date/Time <br /> 4. L� SANITATION PERMIT <br /> Job Address/L ation 7/ <br /> Ow r Address e r <br /> TIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ! <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER £ t <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site # <br /> .r <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 /> Piant 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 /> Y <br /> I <br /> I hereby certify that I have prepared is application and that the work will be done in accordance with San Joaquin County ! <br /> ordinances, state laws, and rules r guiations of a an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X l <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &4 ived gej0aKnua,y 31 ❑ July 1 &Received By July 31 <br /> .I BILLING REMITTANCE REMIT + <br /> BASE EXPLANATION HECKED <br /> DATE DAT MI{C+TED AMOUNT DUE AMOUNT <br /> FEE c <br /> LESS €} <br /> PRORATION 7 <br /> PLUS t <br /> PENALTY <br /> OTHER I <br /> v <br /> OTHER <br /> + _n7W .Y �'Co <br /> Received by Date Receipt No. Permit No. Issuance Date Ma ed- Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKTON,CA 95201 <br />