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Applications Will.Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (Fdr Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> - Application is h sby made to c rry on burin ss in the jurisdictional area of the San oaquin cal Ha�alth/District <br /> !tss Name( A) —_, Adress L as n <br /> aOwner Address �"�-�• I <br /> Firm Partners, Addresses and Telephone humbers Vj <br /> A Business Telephone No. "90.5 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name(Print) Title Date ��' ��'�Z <br /> Please check Applicable Category(1-7)and Fill in the Required Intolfation. V <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) ::11 <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.S.or R.C.E. Name R.S.or R.C.E.No. j <br /> Test ition Test Date/Time <br /> 4. <br /> Test <br /> PERMIT <br /> Job Addre ocatie,;,Y-2 Address IM46_r <br /> —//��Q/ <br /> UP,SEPTIC TANK 13 CESSPOOL LEACHING FIELD LTec7�^MCTT ❑ PACKAGE PLANT U ' 0 '+ <br /> WP <br /> PERMANENT ❑ TEMPORARY ❑ NEW ' (r REPAIR ❑ OTHER <br /> � ❑ CHEMICAL TOILETS For July 1,-June 30, 19 { <br /> Pe Construction Disposal Site f ^1 1 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30,19 <br /> Operator Name Where Certified {1 <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/Mc. <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 ruips and regulations the Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X A ] <br /> FOR DEPARTMENT USE ONLY <br /> Fee to Due:❑ ANNUALLY 13.PFR UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1&Rebaived ay July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED \ <br /> GATE DATE REMITTED AMOUNT <br /> FEE Q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> { <br /> OTHER <br /> OTHER <br /> j( E <br /> u � ! � Y <br /> Received by "�� Dale Receipt Na. Perrnit No. esus Deka Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/BERVICES tent E.HAMILTON AVE.,P.O.aoa Wall STOCKTON,CA 95201 <br /> - c <br />