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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 /> V( ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is tiereby ma to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> , <br /> F Business Na DBA) Q Jr-'1 Address <br /> z Owner � ' ^� Address <br /> a <br /> Firm Partners, Addresses an le?°ne Num erers G f <br /> � dT <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) t I „o 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) 4 <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 <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. � SANITATION PERMIT t� /�_ �� <br /> Job Address/Locat�jn r.2 X Fi dGC.�� `f p29� <br /> Owner�r�J(J>QA Address --"' <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER l 544► <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 (� <br /> Type Construction Disposal Site \! <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 411 <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 /> 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, and rule d're�latiioons of the;IFn Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - ':z <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receive July 31 <br /> BILLING REMITTANCE $ IT <br /> BASE EXPLANATION AMOUNT DUE NECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEEqgao <br /> LESS <br /> PRORATION r' <br /> i lyl� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered— <br /> APPLICANT—RETURN <br /> eliveredAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA95201 <br /> :1>:Ga6km ®3 <br />