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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> k (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> Al LIQUID WASTE <br /> Applicatio 's h eby d rry us' a in the jurisdictional area of the Sar Joaqui Local Health istrict /J <br /> ness a (DBA) "CIO <br /> i Owner ` Address <br /> 0 Firm Partners, Addresses and Telephone Numbers Y <br /> a Business Telephone No.=3 P•�5 J�/AA_ <br /> Emergency,Telephone No. <br /> Contractor Licence No- �� 7z <br /> f L Applicants Name (Print) cc-;e 5/7—z4c Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information (/1 <br />' 1. ❑;PUMPER VEHICLE PERMIT REGISTRATION (FOR!_EACH VEHICLE) �r��� <br /> For July 1, June 30, 19 Disposal Sites <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.'0 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 j — Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addre /Location C7 'z'` eve <br /> Owner Address— 62; <br /> ,❑ SEPTIC TANK ❑ CESSPOOL R-LEACHING FIELD EYS_EE_PAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW Ia'REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction . Disposal Site r <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: w❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and thaYthe work will be done in accordance with San Joaquin County <br /> ordinances, state laws, aad3ules.and reg ns f the San Joaquin Local Health District. <br /> _ <br /> E APPLICANT'S SIGNATURE <br /> 3 <br /> � A <br /> FOR DEPARTMENT USE ONLY <br /> f <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 [].July 1 &Received By Juiy 31 <br /> BILLING REMITTANCE $ REMIT <br /> SASE EXPLANATION AMOUNT DUE CHEED <br /> DATE DATE REMITTED <br /> �j A U T <br /> FEE 4 <br /> LESS y <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> IL <br /> I -Received by Date Receipt Nm Permit No. Issualrice Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />