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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transterable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> Y` <br /> LIQUID-WASTE <br /> Applieation�e,.r�made Car /n 7b,�,siness in a urlsdie ional.area of the San Joaquin Loyal Health District <br /> nusiness Nam ( BA) l A/ 1J D�s-/� �� 1�>r Address �7©r .2 A �Q�f.����/r <br /> Owner_ W�' Address ClvlSJ � <br /> Firm Partners, Addresses and Telephone t4umbers <br /> Business Telephone No. & Em_ _ergency Telephone No. <br /> Contractor Licence No. 6 _ <br /> L Applicants Name (Print).— Title Date M--st <br /> Please check Applicable Category(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., 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 /> 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/Location ?,i&S'-Q _-,.I- <br /> Owner r' � sT_ `c9 Address !3 a2 b� A/ _�r�e_� <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD EKSEEPAGE PIT ❑ PACKAGE PLANT i <br /> A PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> e Construction _ Disposal Site G_ <br /> rvo. of Units Equipment Storage/Cleaning Location(s) ^� i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified 1 <br /> Plant Location <br /> Plant Capacity —j <br /> ___...........—_._—_......_._..T._. No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 - l <br /> SIZE: ❑ Less Than 1.000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. _ _.... <br /> I hereby certify that I have p red this app' n and t t the work-wltl be done in accordance with San Joaquin County t <br /> ordinances,state <br /> law <br /> an les nd gul ons the S Joaq Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> P <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due., ❑ ANNUALLY ❑PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 a Receiveo By July 31 <br /> REMIT <br /> BASE EXPLANATION —BILLING , -REMITTANCE-.,_ $ AMOUNT DUE CHECKED <br /> DATE —,DATE REMITTED AMOUNT <br /> —..-------- ;.. <br /> ys <br /> FEE <br /> _ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY lr <br /> OTHER <br /> OTHER - 1 <br /> Received by. Date Receipt No PermitlNo. Issua to Mailed Delivered. f <br /> APPWCANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES 16019 H AVE,P.O.Bdx 2009--STOCKTON,CA 95201 T <br />