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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 JoaqyW Local Health District <br /> N Business Name (DBA) •�. 1�r/'GG �. Address pa Y <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers J <br /> a. Business Telephone No. f � Emergency Telephone No. dCl <br /> Contractor Licence No. <br /> Applicants Name (Print) ; f Title �scE_ fIfDate�� X7 <br /> Please check Applicable Category (1-7)and Fill in the Required Information rl� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �1 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Lic.-,"e 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 <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 <br /> Address a9': �'r �7kJ>ye 1,,� - <br /> Isd SEPTIC TANK ❑ CESSPOOL "LEACHING FIELD 11 SEEPAGE' <br /> 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 /> 0, 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 r gulati ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT-USE ONLY` 4 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Ja 1 &Received By January 31 ,❑ LIQ 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTA GE $ <br /> BASE EXPLANATION DATE -DATE REMITTED AMOUNT DUE- CHECKED <br /> AMOUNT <br /> FEE 6/377 <br /> LESS <br /> PRORATION " <br /> PLUS <br /> PENALTY <br /> OTHER <br /> w OTHER r <br /> Received by Date Receipt Na. Permit No. Issuance Date Mail Delivered 3. — <br /> APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />