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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. m <br /> -- APPLICATION <br /> F (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio is hereby made t carryon business in the jurisdictional are the San Joaq 'n Local Health District <br /> Or Business Name (DBA) e s 9 Z &"NP46 C7- e� <br /> ' a Owner V *—XIAIR-04 Address A 4.oWA- <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> � Contractor Licence No, <br /> L <br /> Applicants Name Print .� TitEe 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. License Renewal No. K. <br /> Capacity Gal., Weights & Measures No. <br /> k Equipment Parking Address <br /> fl 2. ❑ PUMPER YARD � - <br /> For July 1, June 30, 19 V' <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. IV SANITATION PERMIT <br /> Job Address/Location - <br /> Owner Cf} 2 O,L 4 fifes Z Address z 3 in ,4 -W eff AJ iO C c_'T �T�T�� <br /> SEPTIC TANK El CESSPOOL 11 LEACHING FIELD ❑ SEEPAGE PIT El PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site (V <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County �1 <br /> ordinances, state laws, and rules and regulations of the Pri Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ON <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑,EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE, CHECKED <br /> AMOUNT <br /> FEE �U <br /> LESS 3 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER k <br /> OTHER "f <br /> Recei ed b - Date Receipt o. Permit No, Issuance ate - Mailed Delivered -, <br /> 'APPLIC NT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />