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ApplicationsWill Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> I LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District . <br /> ' y Business Name(DBA) <br /> Address > <br /> r Owner, hl Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. h <br /> ;Contractor Licence No. i./A Emergency Telephone No. -Sr? <br /> i L Applicants Name (Print) Title <br /> Please check Applicable Catego (1-7) and Fill in the Required Information Date <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) M <br /> For July 1, June 30, 19 Disposal Sites I/ <br /> Description(Make/Yr., Color) <br /> Contractor _Address License No. <br /> Phone <br /> �y..NfiL�i4F�fniti�'lydS'r;35"ss - 1 <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 /> 4. q SANITATION PERMIT f� <br /> Job Address/Location 7 y .�y�j7-x �� �� 10:7 <br /> Owner �i Address 9J� `r A���r <br /> ❑ SEPTIC TANK 11CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR E] 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. V <br /> 1 <br /> i <br /> - F <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, any rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> C�A� 3 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH _ ❑-January 1 2,Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> x <br /> LESS j <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ® e <br /> Received by d cry s-7 <br /> Date ' <br /> Receipt No, Permit No. Iss nce ale �'Mailetl "De <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA ON AVE.,P.D.Boy 2009 STOCKTON,CA 95201 <br />