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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> s° (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA} Address <br /> z Owner Q4 r Address .5� �� <br /> 4 <br /> Firm Partners, Addresses and Teleph ne Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title ®H✓!!��^ Date .. <br /> Please check Applicable Category (1-7) and Fill in the Required 9formation f„ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) V <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 ; .. al.,Weights & Measures No. <br /> Equipment Parking AdPM - - <br /> 2. ❑ PUMPER YAR'bi ~ <br /> For July 1, June 30, 19y. <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.;'E. No. <br /> Test Location Test Date/Time �}1 <br /> 4. ®'SANITATION PERMIT �� ' 7" + <br /> Job Addre ocatio , 14 65 0 v�� i <br /> n44, oOwner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL t7bd LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR `"❑(OTHER C_ <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 <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: ❑ 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 repared this application and that the work will be done in accordance with San aquin County <br /> ordinances, state laws,�ra :rules and egula ions cq a Sa . oaquin Local Health District. _ <br /> APPLICANT'S SIGNATURE M <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT [7 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July I &Received By Juhy 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> / <br /> FEE it G�Cf' / ")�bU /�7 <br /> LESS �"J CJ <br /> PRORATION <br /> PLUS @ U <br /> PENALTY ^ 'D <br /> OTHER N <br /> OTHER L v <br /> / tea <br /> Received Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />