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APPLICATION <br /> r Non-Transferable, Revocable,and Suspendat <br /> ENVIRONMENTAL HEALTH PERMIT'-' SEPTAGE <br /> LIQUID WASTE <br /> Application is emadeto carry on siness in the Jurisdictional area of the Sa oaquin Local Health District <br /> �dusiness reby Name (DBA �� p�-�- G-� Addresssf /�emc 1?e�. <br /> Owner 7 -r[�4 ar Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> `usiness Telephone No. Emergency Telephone No. <br /> J.Contractor Licence No. . <br /> -Applicants Name (Print) Title el�Lt e-eL Date ew"J � <br /> ?lease check Applicable Category (1-7) and FIII in the Required Information <br /> ", ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 0 <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 /> -*. ❑ PERCOLATION TEST , <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time -- <br /> ❑ SANITATION PERMIT <br /> Job Address/Location <br /> 0 1 Address <br /> IGD SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT. <br /> -❑ PERMANENT ❑ TEMPORARY ❑ NEW 11 ❑ REPAIR 11 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site -. <br /> ,iaallo. 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 /> T. ❑ LAUNDRY For July 1,-June 30, 19 - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> li-❑ 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 ulatio s of the San Joaquin Local Health District. <br /> ,APPLICANT'S SIGNATUREX <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑'January 1 a Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE - REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY '? <br /> OTHER <br /> OTHER <br /> D 834 0 "Sa <br /> gaceived by Date Recelpt No, Permit No. Isiluince D e Maned Dallverad <br /> la.' I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 150L E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 962 - <br />