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Applications Will Be Processed When Submitt4properly Completed:Be Sure'To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) 4 <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is reby made to arry on bu 'ness in the juris ' tional area of the Sap Joa uin Local Health Di rct <br /> rn Business Name BA) Address <br /> a Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. f 5 Emergency Telephone No. f <br /> Contractor Licence No. 7—�7_ <br /> LApplicants Name (Print) Title _ � �• Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites r <br /> Description(Make/Yr., Color) I <br /> Serial No. CAL.iLicense No. CAL. License Renewal No. <br /> Capacity Gal., We,igtlts &i Measures No. <br /> Equipment Parking Address I <br /> 2. ❑ PUMPER YARD ' <br /> For July 1, June 30, 19 i <br /> No. of Vehicles Stored t <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. ❑ SANITATION PERMIT <br /> Job Address/Location � ) � (V_4 Gc-rs-r <br /> Owner Address_F49 <br /> ❑ SEPTIC TANK ❑ C SPOOL EKLEACHING FIELD C�"S AGfrPIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW UaREPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 GJ <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 /> 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. t <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 ari egulations of the 5 oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 14 - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE <br /> BASE EXPLANATION AMOUNT REMIT <br /> DUE CHECKED t d <br /> 1 DATE DATE REMITTED AMOUNT <br /> FEE 4 C 6 <br /> l c� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY L i <br /> OTHER <br /> OTHER <br /> i <br /> L114b <br /> Recetved by Date Receipt No Perryiit No. issuance Dam Mailed Delivered h <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM IT/SEAVICES' 101 E.HAZELTON AVE.,P.O.Box 209 STOCKTON,CA 95201 , <br />