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Applications Will Be Processed When Submitted Properly Completed. Be Sure To$ign The Application.,— <br /> APPLICATION <br /> pplication.",M,,,APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made-to-parry on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness N, ne (DBA) Address <br /> cOwn e. Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. s 3 —.zG� b Emergency Telephone No. 0 <br /> Contractor Licence No.. <br /> LApplicants Name (Print) ` e Title 179WAI Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 Disposal Sites I <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 <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 /> I , <br /> t 4. ❑ SANITATION PERMIT • <br /> i. Job Addr ss/Location <br /> _(: j Owner l <br /> r. �y�ti/•��o�.�✓ Address FReA <br /> r .SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ` 5LPERMANENT ❑ TEMPORARY ANEW ❑ REPAIR ❑ OTHER <br /> ( 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ' <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 <br /> I Plant Location <br /> + Plant Capacity <br /> No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> r SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> F ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - - <br /> 1 <br /> C <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, stale laws, a rules and regulations he San Joaquin Local Health District. <br /> k PA -;'!*: �e,� ?R <br /> APPLICANT'S SIGNATURnnE��X y� <br /> k 2 8O Xyl k".& 1rw�1 'Cid. o-►, • 4 S L H t7 <br /> k 0 A <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Ju{y 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION��� AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS �� <br /> PENALTY <br /> OTHER <br /> .� <br /> OTHER . <br /> Received by - Date Receip o. it!;No. Issuance Date � Mailed - <br /> �i�' - _ APPLICANT—RETURN ALL COPIES TOE -ENVIRONMENTAL HEALTH PER_MIT/SERVICES 1601 E.FIAZELTON AV P.O.Box 2009 STOCKTON,CA 95201 <br />