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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE a <br /> LIQUID WASTE <br /> Applicatlii ere �adpe ttoo carry o mess in th�isdictional area of the San Joaquin Local Health District <br /> wBusiness Name (DBA) �.4+ l k%z4 �^( 5,+ --tom- Address � <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No, Emergency Telephone No. <br /> Contractor Licence No. _ <br /> Applicants Name (Print) AASTitle k Date <br /> Please check Applicable Category(1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) S <br /> For July 1, June 30, 19 Disposal Sites - <br /> J <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc Ise 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..'E�SANITATION PERMIT <br /> Job Addre s L cation <br /> Owner00LAddress <br /> ❑ SEPTIC TANK , ❑ CESSPOOL XLEAC1 ING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> XPERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER i <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 N <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 ' <br /> Operator Name Where Certified I <br /> Plant Location i <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 r , <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.. <br /> i r <br /> f 1 <br /> I hereby certify that I have prepared this applicat' and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and tionvft�- n Joa uin Local Health District. j <br /> APPLICANT'S SIGNATURE X <br /> CASQ,&_ <br /> FOR DEPARTMENT USE ONLY <br /> Fee I5 Due: © ANNUALLY El PER UNIT PER SITE ❑ EACH ❑ January 1,&Received By Ja uary 31 El July 1 &Received By July 31 - <br /> _- REMIT ; <br /> BASE EXPLANATION BILLING REMITTANCE $ CUNT DUE I CHECKED ] <br /> i DATE DATE REMITTED AMOUNT }t <br /> t 1 <br /> FEE <br /> 3 <br /> LESS J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Dat Mailed Delivered <br /> APPL4CANT—RETURN'ALL COPIES.TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - moi E.HAZELTON A .O.$o■2009 STOCKTON,CA 95201 - <br /> r <br />