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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION i <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE _ <br /> Applicati n is ere made�jo arty n b Hess in the jurisdictional area of th San J aquin Local Health District <br /> rn Business Name (DBA) ..�. I7. (.�1 Address <br /> C7__/ �J-� <br /> z Owner Address <br /> a a <br /> 2 Firm Partners, Addresses and Telephoner Numbers <br /> aBusiness Telephone No. ya! + n 7 _ Emergency Telephone No. <br /> Contractor Licence No. 3 y <br /> L Applicants Name (Print) {'ti/ Title 77s�7. �r/' 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) <br /> Serial No. CAL. License No. CAL, Liccnse Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address 1 <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. PO SANITATION PERMIT <br /> Job Addr s/Locatnion �• ` S� S r <br /> Owner �o 'Z Address_ <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1. -June 30, 19 <br /> Type Construction Disposal Site <br /> .W ; <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 /> 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 /> A <br /> I hereby certify that I have prepared this application and that the work will be done in accorCounty <br /> ordinances, state laws, and ules and regulations of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATU X <br /> IF <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Recei d By January 31 ❑.July 1 &Received By-July 31 <br /> BILLING REMITTANCE $ REMIS, I <br /> BASE EXPLANATION DATE DATE EMITTED AMOUNT DUE CHECKED <br /> �O <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ' <br /> I <br /> i OTHER <br /> OTHER <br /> I � !�7y i <br /> Received by - Date Receipt No. Permit No 4.s .nc Date Mailed Delivered <br /> -APPLICANT—RETURN ALL COPIES TO:.' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C 21 F_ I <br />