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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> w <br /> APPLICATION <br /> ,r (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 /> Q'iness Name(DBA) !:F,- '1� soiY Address 'off"�.a''" <br /> aOwner Address <br /> J Firm Partners.Addresses and Telephone Numbers <br /> a Business Telephone No. -'`+� - %�� <br /> a p Emergency Telephone No. 7t1 <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date l <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 t <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. Licc;se 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 /> A. ❑ SANITATION PERMIT <br /> Job Address/Location ��b' h Y�H/�� �G9'y j . T3-,9G tr' c�Ct <br /> Owner Address <br /> JO SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT rn <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER t11 <br /> ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Construction Disposal Site <br /> o. 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 /> 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 Vd regulations of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X r'��• <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> PEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER or <br /> �a t <br /> Received y to Receipt No. P rmi o. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />