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t, Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION } <br /> p (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> X\ - LIQUID WASTE d <br /> f Application-is hereby made to carry on business in the jurisdictional area of the San Joaquin Local,Health District <br /> yBusiness Name (DBA) I—, 4,v 7-11 06fv "'r s o N Address i�`O 'Tax //Cl �lac/esl4-> <br /> zz Owner Address <br />{t 9 Firm-Partners, Addresses and Telephone Numbers f <br /> I a Business Telephone No. -tea 3�y /� Emergency.Telephone No.— <br /> J Contractor Licence No. 6 6 S86 <br /> Applicants Name (Print) -- Title Date 1 <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> III For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc?se Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. El PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> z 3. ❑ PERCOLATION TEST <br /> R.S. orR.C.E. Name R.S. or R.C.E. No. �s <br /> Test Location Test Date/Time a <br /> 4. 'Er SANITATION PERMIT <br /> Job Address/Location <br /> Owner tO����41 S h iY s Address <br /> P ® ❑ C1 PACKAGE PLANT SEPTIC TANK CESSPOOL ® LEACHING FIELD SEEPAGE PIT <br /> I N PERMANENT ❑ TEMPORARY ® NEW ❑ REPAIR ❑ OTHER <br /> I 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> t Type Construction Disposal Site <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 /> Plant Location. <br /> Plant Capacity No. Units Served <br /> 4 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 inaccordancewith San.Joaquin County J <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X ` <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑-PER UNIT' ❑ PER SITE ❑r EACH ❑-.January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED- <br /> `,( / DATE DATE REMITTED AMOUNT <br /> FEE Gi - <br /> Wrr <br /> i <br /> p LESS + <br /> - PRORATION <br /> PLUS 1 <br /> PENALTY <br /> l OTHER <br /> OTHER <br /> Received by Date Receipt No. , Permit No. Iss ante Qate Mailed Delivered <br /> 4 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL,HEALTH PERMI T%SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 .. <br />