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Appucanons win oe rrocesseu wnen auomnreo rropeny t•.omptetua. oe OUre t u myn I ne Hppum,w,,. <br /> APPLICATION CDC <br /> '1rAr Non-Transferable, Revocable, and Suspendaty 7 <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i hereb m e to car n business in the jurisdictional area of the San oaquin Local Health District _ <br /> n Business Name (DBA)�,T 1 y L`G 2 Address fw >� r �9 M > <br /> Owners Address <br /> Firm Partners, Addresses and Telephone Numbers _ <br /> iBusiness Telephone No. �•Z Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title�/f�11 2 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.Llc�nse 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 e4 <br /> •T v <br /> Job Address/Location <br /> Owner - G Address <br /> EPTIC TANK ❑ CESSPOOL UKEACHING FIELD ❑ SEVAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW W<EPAIR ❑ OTHER <br /> 0 <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction - Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) 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 /> 1 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 a�DfS of 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 $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTEDU(/ AMOUNT <br /> FEE X5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER �( <br /> Received by Date Receipt No. Permit No.. Issuance Date Mailed Delivered , <br /> INI <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sor 1009 STOCKTON,CAI _ <br /> �1�.. sed. ��_ <br />