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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> . x . APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) / SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in.the jurisdictional area of the San Joaquin Local Health District- <br /> O Business Name (DBA) 4 7T_�I`-. ,Address y 3 t <br /> aOwner ; Address - <br /> 0 Firm Partners, Addresses and Telephone Numbers 17 <br /> CL <br /> Business Telephone No. Emergency Telephone No. - <br /> Contractor Licence No. 1>o L <br /> Applicants Name {Print) Title /gAe'&RA�- Date <br /> Please check Applicable Category (1-7)and fill in the Required Information , <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ti <br /> For July-1, - ' 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 <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored - <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or.R.C.E. Name t : 'n-R.S. or R.C.E. No. <br /> Test Location jTest Date/Time <br /> 4. ❑ SANITATION PERMIT ` <br /> Job Address/Location <br /> Owner N Address <br /> EP-SEPTIC TANK ❑ CESSPOOL' EACHING FIELD ❑SEEPAGE PIT ❑ PACKAGE PLANT <br /> i ❑ PERMANENT ❑ TEMPORARY ❑ANEW I ❑ REPAIR ❑ OTHER `R <br /> i 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _�_ F <br /> r s , <br /> Type Construction I Disposal Site— <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> i 6. ❑ PACKAGE TREATMENT PLAN ForJuly 1,—June 30, 19 <br /> Operator Name Where Certified s �� <br /> k s <br /> Plant Location <br /> 'Plant Capacity e k 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 in'accordance with San Joaquin County <br /> ordinances, state laws,.and-rules and gul ns of the•San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Rue: ❑ ANNUALLY .:. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING EMI ANGE $ <br /> BASE, EXPLANATION .DATE - AJ '-REMITTED AMOUNT DUE CHECKED <br /> � AMOUNT <br /> FEE z4 x"I le <br /> LESS <br /> PRORATION <br /> PLUS_. -.^,t�r F :,►.-,:. _.rte _. - - _..__. _ <br /> PENALTY <br /> OTHER <br /> :;T OTHER <br /> /,57-2:2 - I <br /> Received by Date Receipt No Permit No Iss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601.E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201' <br />