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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �w <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH:PERMIT SEPTAGE <br /> LIQUID WASTE <br /> AppI(cation ' hereby mad to carry oOnu in he ju 'sdiictional area of the S n Joa In Local Health District <br /> FBusiness Narr (DBA) Address � H vYa <br /> r .4Owner Address Firm Partners, Addresses and Telephone N bers <br /> 4 <br /> a Business Telephone No. —J` Emergency Telephone No. �} <br /> j Contractor Licence No. Zlv <br /> L Applicants Name (Print) J Title Date '/S I?? <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 /> W; <br /> Description(Make/Yr., Color) ..:i <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity Gal., Weights & Measures No. <br />' Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 _ hili <br /> I No. of Vehicles Stored i I <br /> No:-of-Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST �. <br /> a R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT'7�9A,,_ tj <br /> r Job Addr s/Location <br /> r Ow er Address <br /> PTIC TANK ❑ CESSPOOL l-LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE ANT <br /> '�' PERMANENT ❑ TEMPORARY to NEW ❑ REPAIR ❑ OTHER ;I <br /> 5. ❑ or , -June 30, 19 CHEMICAL TOILETS F 'July 1 <br /> p <br /> Type Construction Disposal Site } <br /> No. of Units Equipment Storage/Cleaning Location(s) i <br />` 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified $ <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -idne 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 <br /> I hereby certify that I have prepared this application and that the work will be done in ac ordance with San Joaquin County <br /> ordinances, state laws, and r es and regulations of th an Joaquin Local Healt Distric . �t <br /> APPLICANT'S SIGNATURE X <br /> , f <br /> , // FOR DEPARTMENT US LY l <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT L9 _PER SITE ❑EACH nuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i <br /> BILLING E TANCE $ REMIT s <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> P! DATE DATE REMITTED AMOUNT <br /> FEE � , <br /> LESS <br /> PRORATION i <br /> PLUS r <br /> PENALTY <br /> OTHER <br /> Pp <br /> I <br /> .OTHER >I - <br /> .0 6 V <br /> Received by - Date Receipt No. Permit No. - Issta nce'D to - .Mailed Deli ere ,' <br /> APPLICANT—RETURN ALL COPIES TO:'� ENVIRONMENTAL HEALTH PERMIT/SERVICES « 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 201 <br />