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Ff Applications Will 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 hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,,7 Business Name (DBA) Address ���' �oX //d /J'/7 V6:'1.0 42 <br /> 4 Owner.._ Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No, S''� Emergency Telephone No. <br /> Contractor Licence No. f<6-.386 <br /> Applicants Name(Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information O <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. GAL. 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 caV <br /> 3. ❑ PERCOLATION TEST l <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time V <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 88fi e >-. Tis 4 vie AIk7c-C.4 ems, <br /> Owner eT©it/ /`7�0 �j� Address 8 ! F:�"ATis ,lav e �irZe <br /> ® SEPTIC TANK ❑ CESSPOOL 91 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ® PERMANENT ❑ TEMPORARY ❑ NEW ❑ 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 /> 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepared this application and that the work will be done in accordance Joaquin Count <br /> ordinances, state laws, and ru s and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due'. 13 ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 1 July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No. Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AV£.,.P.O.Box 2009 STOCKTON,CA 95201 <br />