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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. y <br /> APPLICATION <br /> (For Nan-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br />'i LIQUID WASTE <br /> I° Application is reby made tp cam on business in the jurisdictional area of the Sa aaq Local Health District <br /> rBusiness Name (D ) �* Address , �' 72 7. <br /> z Owner Address -�— <br /> a <br /> J Firm Partners, Addresses and Telephone Numbe <br /> aBusiness Telephone No. ie Emergency Telephone No. <br /> Contractor Licence No. 2- <br /> Applicants Name (Print) -� Title p—�----' Date <br />! Please check Applicable Category (1-7) and Fill in the Required Information <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. CAL. 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 <br /> 3. ❑ PERCOLATION TEST <br /> r 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 /> �y 5 7/ 4 <br /> Job Addres ovation d( <br /> Owr TI ANK ❑ C SSPO EACHING FIELD Address Z <br /> PSEEPAGE PIT ❑ PACKAGE PLANT <br /> DIPPER ENT 13 67 <br /> C�<EW ❑ REPAIR ❑ OTHER i <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) V+ <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 J <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 /> i <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 s nd reqWAJions_91,the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &'Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> may. MOUNT <br /> FEE q � <br /> LESS <br /> PRORATION <br /> i PLUS <br />` PENALTY <br /> t <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. - I uanc 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 />