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Applications Will Be Processed-When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> Non-Transferable, Revocable, and Suspendabi <br /> �tENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applica ' n is�h reby ade t carry on bu in s int jurisdictional area of th Joaqu Local Health District /_ <br /> y Busines ame (DBArM�: Address t�- 7l`7 ��1 <br /> z Owne Address z � <br /> Firm Partners, Addresses and Tel pho a Numbers <br /> CL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title 1 Date <br /> Please check Applicable 606gory (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., COI&) <br /> Serial NO. CAL. License No. CAL. Uccnse 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.0.E. No. <br /> Test Lo tion Test Date%Time - <br />`{ 4. las SANITATION PE fT f:��Job Addr s ovation <br /> Ownerdr <br /> Address. <br /> ❑ SEPTIC TAN ❑ CESSPOOL "TEACH NG,F1ELD ❑•SEEPAG€ PIT ❑ PACKAGE PLANT } - <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW -.59--REPAIR _ �g <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> Flo. of Units Equipment Storage/Cleaning Location(s) <br /> ;. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 s <br /> )perator Name Where Certified <br /> 11ant Location <br /> ant Capacity No- lJnits Served <br /> ❑ LAUNDRY For July 1, -June 30, 19 <br /> ?E: ❑ Less Than 1,000 Sq:Ft., ❑ More Than 1,000 Sq. Ft. <br /> },DRY C,/LEANING, Chemicals Used/Amount/Mo. <br /> l �` ,.i s r2: c ,,.s✓R S R Cis ; - <br /> Inc...s"1 FF"r!j 1, ti <br /> � '•ik, .,�h t;`_ -�.,T It _i �J%�,I lel,,cj fI hereby certify that I have prepared this application and that the work.will be done in accordance with San Joaquin Couordinances, state laws, and ales and-regu ion of the San Joaquin Local Health District. <br /> _ICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received ByJanuary 31 ❑ July 1 &Received <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE GATE REMITTEp AMOUNT DUE CHECKED <br /> AMOUNT <br /> ($ s <br /> EE <br /> ESS <br /> AORATION <br /> I.US <br /> :NALTY <br /> [HER Ir/ <br /> / <br /> }} <br /> IHER j <br /> 'eived by Date Receipt No. Permit No. if8uancff Date Mailed Delivered <br /> ;PLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 - <br />