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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication <br /> APPLICATION <br /> (For Non-Transferable,.Revocable, and Suspendable) i <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> I LIQUID WASTE <br /> Applicatiojp�is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name DBA)!-n t,1 a e PV _ Address <br /> zOwner C v- Address ' <br /> Firm Partners, Addresses and Telephone Numbers e <br /> aBusiness Telephone No.92/7— 74-` Emergency Telephone No. <br /> Contractor Licence No. 3 -7C 5 • <br /> Applicants Name (Print) r Title Date Q. 1 <br /> Please check Applicable Category (1-7) and Fill in the Required.Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.; Color) <br /> Serial No. CAL. License No. GAL Licc,-se 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 <br /> Job Address/Location5 <br /> Owner a Ad ress 7 S 0. -1y'l-tv <br /> L ❑ SEPTIC TANK 13 CES OOL LEACHING FIELD %SEEPAGE PIT ❑ PACKAGE PL NT <br /> ❑ 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 W <br /> Where Certified <br /> Operator Name <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. Fl. �f1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I I hereby certify that I 11e prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, nq rules and r,gul t' ns of t San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH. ❑ January 1 8,Received By January 31 ❑ July 1 &Received By July 31 -a <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT } <br /> FEE <br /> F <br /> LESS <br /> PRORATION <br /> - t <br /> PLUS <br /> PENALTY <br /> OTHER "+ <br /> r <br /> OTHER <br /> 4 0 '83L// C <br /> Received by' - Date- Receipt No. Permit No. Iss ante D to - Mailed Delivered - t <br /> APPLICANT--RETURN-ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES - - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201�� <br /> W <br />