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Applications Will Be Processed When Submitted Properly Completed. Be Sure TO Sign The Application.—Y <br />' APPLICATION <br /> (For Non-Transferable, Revocable;and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGI <br /> LIQUID WASTE <br /> Applicationis er y m_�oc <br /> on u iness in the jurisdictional area of the San Joaquin Local Health Dist ' tj <br /> rn Business Name (DBA) Address <br /> a Owner Z Address <br /> Firm Partners, Addresses and Telephone Numa. bers - <br /> Business:Telephone No. Emergency Telephone No. <br /> �Contractor Licence No. <br /> L Applicants Name (Print) Ti#les - r Date `^ <br /> Please check Applicable Category (1-7)and Fill in the Required Information Cxr <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) '` 4 '` •M"O``'' "r� " � <br /> For July 1, June-30, 19 — -, Disposal Sites - If <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 <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets Stored t + <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. n l <br /> Test Location Test Date/Time k "# <br /> 4. ❑ SANITATION PE"IT r f Q f <br /> Joh Address/L ati n I 'V o We-I l�(�(' (31r �O <br /> ner C ►'�' 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 }t � <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 r� <br /> Operator Name Where Certified 'f <br /> • <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., ElMore Than 1,900 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ; <br /> Home owner or licensed agent's.igentwe certifintthr,followimp.':l et•rtify tebotintheo:the work fori0ichthis pEtmn t is issued,I shall rret employ any perso <br /> t. in such manner as to become subiect to-urTk zi it s .r 10E:74�tiF)n i yrs of Cal;:`erniu i <br /> Contractor's hiring or sub-cGr:aractir: si nr.tive'{ r i i s :i fQl�AWng; ' evrtii}'that ir,;he per Q1L-man0L1 ri the:vork fort:NCh this permit is issued,I shall <br /> employ persons subjecf to workman's C41:1;wrise,ail iJ}tis' t iafiicrrl;a.' — 4, _ _ _ <br /> I hereby certify that-! have prepared-this plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and les_ ndreauI tions f the a oaquin Local Health District. ' <br /> APPLICANT'S SIGNATUREX 11 f <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑-ANNUALLY ❑ PER UNIT- ❑ PER SITE { <br /> + ❑ EACH Q January 1 &Received By January 31 ❑ July 1 &Received ByJury:31' y <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE .$ r <br /> - - - AMOUNT DUE CHECKED <br /> DATE ,DATE. REMITTED <br /> - AMOUNT •� 1 <br /> FEE -r,. ; .. .: C <br /> f 44 <br /> LESS _ �..__ <br /> ' PRORATION .. 1• I "- '} J f - - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> -- s 1Jr <br /> -OTHER <br /> Received by ate Receipt No. Permit No. Issuance Dat mailed Befivered - f. <br /> APPLICANT—RETURN ALL COPIES TO:- - ENVIRONMENTAL HEALTH PERMIT/SERVICES•- - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />