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ApplicationsWill 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 <br /> LIQUID WASTE <br /> Application is rebs made a carry on business in the jurisdictional area of the San oaquin Local Health Distric <br /> Business Name (D A) <br /> ` a Owner Address - <br /> Firm Partners, Addresses and Telephone Numbe Address <br /> aBusiness Telephone No. S/p .5 � <br /> Contractor Licence No, —Z�(r, Emergency Telephone No. <br /> L Applicants Name (Print) _ =! <br /> n the Required Information <br /> Please check Applicable Cate o ( <br /> ) _ '-Title = Date ' J� HCl <br /> 1. C3PUMPER VEHICLE PER TREGISTRATION (FOR EACH VEHICLE) ` <br /> For July 1, Jurie 30, 19 <br /> Description(Make/Yr., Colo Disposal Sites <br /> Owner's Name =jK IL r I t 1Q )AUU sss _ --- �ry,••Q,�� �, <br /> ress Kicense No. one <br /> Aadress <br /> 2. ❑ PUMPER YARD It <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored - r <br /> No. of Chemical Toilets Stored " + <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name <br /> Test Location R.S. or R.C.E. No. <br /> Test Date/Time - <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/L cation4�0 _ -4 <br /> Owner <br /> _ -Address <br /> ❑ <br /> SLP I-IC.TANK 11CESSPO ��`�`�j� �P <br /> LEACHING FIELD r,> EpgGE pIT ❑ PACKAGE PLANTiPERM; 7NENT .4* ElTEMPORARY ElNEW r " `' EPAIR ❑ OTHER <br /> $• ' <br /> ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type GDnS0,u ion <br /> ~ Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> 6. 13 PACKAGE TREATMENT PLANT For Jury 1, -June 30, 19 f` <br /> Operator Name { <br /> Plant Location t Where Certified <br /> Plant Capacity <br /> 7. IJLAUNDRY For July 1, -June 30,-19 No. Units Served <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., �O More Than 1,000 Sq. Ft. r � - <br /> ❑ DRY CLEANING, Chemicals.Used/Amount/Mo.. <br /> r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County l <br /> ordinances, state laws, and rules'a regulations of the San Joaquin Local Health District. r ' <br /> APPLICANT'S SIGNATURE X r <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: 111ANNUALLY ❑ PER UNIT PER SITE '9 <br /> ❑ EACH ❑ Januar ` z ' <br /> Y e ed By January 37 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTAN $ . ` REMIT <br /> DATE DAT REMITTED AMOUNT DUE CHECKED <br /> FEE LJ c AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> f <br /> OTHER <br /> OTHER Y <br /> Received by Date Receipt No <br /> Permit No. Iss ance Date Mailed <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM IT/SERVICFSDelivered <br /> 1601 E.HA2ELT0 VE.,P.O.Box 2009 STOCKTON,CA 95201. <br />