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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is her made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,�Business Name (DBA) 7,Y c2-7-r., Address 0 <br /> i Owner ,41 �y G_L c�-� Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> $ Business Telephone No. ��� TI Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) G Title ��r�'7� � Date <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 Llccnse 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.-­El SANITATION-PERMIT -- <br /> Job Address/Location <br /> , , <br /> Owner � Address - <br /> iKSEPTIC TANK ❑ CESSPOOL LEACHING-FIELD ❑ SEEPAGE PIT ❑ PACKAGE hLANT - <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR }may ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 O <br /> Type Construction """a -Disposal Site _7�_ - <br /> No.'of Units Equipment Storage/Cleaning Location(§} <br /> 6. ❑ PACKAGE TREATMENT PLANT- For July-1, -June 30,19" ,r ` <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity- No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 12 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ,. __ <br /> ❑ DRY CLEAN]NG,-Ghem icals 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 and r ulation of,-tt ee, Jan Joaquin.Locai Health District. <br /> APPLICANT'S SIGNATUREXx^°�- <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> n DATE DATE REMITTED AMOUNT <br /> FEE <br /> 4� f V. <br /> -:� <br /> LESS <br /> PRORATION <br /> PLUS 1 <br /> PENALTY Al <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance ate I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES, 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,-CA 95201 <br />