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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 Suspend,,, <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAG� <br /> LIQUID WASTE <br /> Application is reby made to arty on busi s in the'uri tional area of the Sa oaquln ocal Health District <br /> , Business Nam BA) Address <br /> �- - <br /> c owner 42EAddress -� — <br /> c <br /> irm Partners, Addresses and Telep <br /> hone <br /> Numbers <br /> ,'vusiness Telephone No. �L'�✓�G/S Emergency Telephone No. <br /> c <br /> Contractor Licence No. Z 2— <br /> r / ?7!Z—I >' <br /> pplicants Name (Print) Title S: Date <br /> _lease check Applicable Category (1-7) and Fill in the Required 14formation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ""or July 1, June 30, 19 Disposal Sites <br /> lescription(Make/Yr., Color) _ <br /> '75'erial No. CAL. License No. CAL, License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> quipment Parking Address <br /> ❑ PUMPER YARD <br /> 1 <br /> For July 1, June 30, 19 <br /> Jo. of Vehicles Stored r <br /> _Jo. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST \ <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> est L tion Test Date/Time <br /> 1. SANITATION PERMIT <br /> Job Address/Location <br /> Jwner Address y <br /> ,D SEPTIC TANK ❑ CESSPOOL ❑�LEAING FIELD E PIT ❑ PACKAGE PLANT <br /> ^` ❑ OTHER r <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW �tEPAIR / <br /> i. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Dperator Name Where Certified <br /> --Plant Location <br /> Y <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For Jily 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 cer,`y 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 an_OAgulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ A\`.'ALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTA,VCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS L!/' <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ance Date Mailed 'Deli'vered <br /> AooI IrAWT—RFTI.IRN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bot 2009 STOCKTON,CA 95201 <br />