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' Applications Will Be Processed When Submitted Properly Completed,Be Sure To Sign The Application. <br /> Ac APPLICATION :. <br /> r (For Non-Transferable,Revocable,and Suspendable) _ f <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SEPTAGE ;? <br /> LIQUID WASTE <br /> Application is ereby made to garry on business in the iurisdi 'onal area of the San Joaquin Local Health Distrlc <br /> ' HBusiness Name BA) - _ Address D -71,7 -^ <br /> i Owner Address <br /> J Firm Partners, Addresses and Telephone NumIllers <br /> aBusiness Telephone No. -3d F Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name(Print) Z Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required I ormation, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> s <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 /> s. 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> I Test Location - - Test Date/Time <br /> 4. ❑ SANITATION PERMIT e <br /> Job Address/Location 9;2 50 )4&J y <br /> OwnerAddress 7 a <br /> ❑ SEPTIC TANK ❑ CESSPOOL ® . GY T ❑ PACKAGE PLANT <br /> E ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ 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 /> Operator Name Where Certified <br /> Plant Location =-N <br /> Plant Capacity No. Units Served _ <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 ` <br /> SIZE: 1:1 Less Than 1,000 Sq.Ft., 13 More Than 1,000 Sq. Ft. ° <br /> ❑ 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 an -regulations of the Sar <br /> oaq in Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE OWN'.,�R l <br /> Fee Is Due: ❑ ANNUALLY ❑PER UNIT ❑ PER SITE ❑ EACH -- ❑ J. uary B Received By January 31 ❑July I&Received By July 31,rn <br /> ' <br /> BILLING REM 7T"A $ REMIT <br /> BASE EXPLANATION DATE I E REMITTED AMOUNT DUE CHECKED yy AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - f <br /> tOTHER P <br /> 87 7 ! <br /> Received by - Date Rece/ipt'No. Permit No. Issua a Date` Mailed Delivered ' <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIROriMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 j <br />