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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheAppucauon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> N,ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is � �hereby made to c rry o bu ness in the jurisdictional area of the an Joaquin Local Health District <br /> ,Business Name (DBA) �- 17- PACca S� U''1 f Address <br /> — <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. 4 Emergency Telephone No. <br /> a <br /> Contractor Licence No. Ill�Y7%TTJ/- Date <br /> Applicants Name (Print),�fJy J- ^—����s —Title — { <br /> Please check Applicable Category (1-7)and Fill in the Required Inlormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) I <br /> ' CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gal., Weights &Measures No. 0 <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 N <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT S- <br /> Job Address/Location r <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL '. LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT 1.2 X /U <br /> I <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR OTHER X <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. 11PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name f <br /> Plant Location i <br /> No. Units Served <br /> Plant Capacity <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 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> # FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ElJanuary 1 &Received By January 31 ❑ July 1 &Receiv REMITd By uly 31 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> - DATE DATE REMITTED AMOUNT <br /> FEE a.O <br /> k <br /> LESS <br /> PRORATkON <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTQN AVE.,P.O.Box 2009- STOCKTON.CA 95201 <br />