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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applicalion. ,- <br /> APPLICATION <br /> (Far Non-Transferable, Revocable,and Suspendable) <br /> r <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio 's fere y m4 to c"on business in heIsdictional area of the Sa>Jo quin al He Ith istrict /f <br /> ,F Busines a DBA) Address (/ [ <br /> aOwner Address f " <br /> l Firm Partners, Addresses and Telephone umbers IC <br /> aBusiness Telephone No. __ � /� 3 _ Emergency Telephone No. <br /> j Contractor Licence No. <br /> L Applicants Name (Print) Title �_ Dale <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 5 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color)_ 1 <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 i <br /> No. of Vehicles Stored. <br /> No. of Chemical Toilets Stored . <br /> I <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/LPERMIT�� `&3� ��� - L , <br /> Jab Addre ocation ��, ` <br /> Owner Address,, 1_+I„" <br /> f SEPTIC TANK ❑ CESSPOOL LEACHING FIELD _�SEEPAGE PIT ❑ PACKAGE PLANT <br /> El13 ,- <br /> i <br /> r ❑ PERMANENT, ❑ TEMPORARY ❑ NEW D REPAIR ❑ OTHER <br /> }. <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 3 <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 11 <br /> Plant Location - <br /> Plant Capacity No. Units Served <br /> kr 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> 6 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. e <br /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> J <br /> hereby certify that I have prepared this applic I gn /ndat the work will be done in accordance with San Joaquin Countyordinances, state laws, les an egulations foaquin Local Health District. <br /> I` APPLICANT'S SIGNATURE { <br />` FOR DEPARTMENT USE ONLY <br />� Jy <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 P <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED _ <br /> DATE DATE REMITTED AMOUNT <br /> i FEE <br /> LESS CCC <br /> PRORATION <br /> PLUS r1 <br /> PENALTY L_� <br /> OTHER <br /> OTHER t <br /> Received by Date Receipt No, Permit No - Is uance ate Mailed Delivered ` <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2D09 STOCKTON,CA 95201 - <br />