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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 4 r (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is her Vmade to car u ess i the jurisdictional area of the San Joaquin Local Health District <br /> �usiness Name(DBA) 6f - � fin- �� ,y Address 1�,7" _5 ��-,-ram <br /> aOwner �� �c�¢ a(� L- Address 1 Z w? -7 <br /> 9 Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. �� 4" Emergency Telephone No. �7)�Zrb S7C' <br /> -i Contractor Licence No.-_. <br /> Applicants Name(Print)�/�? L�.2 /r_4 Title 1�7-2, Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information .r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July t, 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 r ..........._..—_____........._� <br /> 2. ❑ PUMPER YARD _ �s <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 A.C.E. Name R.S.or R.C.E.No. <br /> Test ocation Test Date/Time <br /> 4. SANITATION PEF%MIT <br /> Job Address/I Lirmnifirin <br /> iPERMner Address ,SEPTIC f, V ❑ CESSPOOL LEACHI G FIELD ) SES �tvTT ❑ PACKAGE PLANTAN ❑ TEMPORARY l4t�wi=�:4 ❑ 4PAA ❑ OTHER <br /> �. ❑ CHEMICAL TOILETS For July 1,-JI `3o, 19, <br /> )e Construction t • _ .,. Disposal Site <br /> —` _-4o.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 /> s <br /> I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,arid rules and re, ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X -- _.�_. v"� _1 _..-- _...... ---- - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑.EACH_..- ❑ January.1&Received.By January31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �' IC AMOUNT <br /> FEE S C�- s <br /> l I <br /> LESS II�� <br /> PRORATION <br /> PLUS r yt11 i <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. uuanc Date Mailed Delivered <br /> • APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 05201 <br />