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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION II <br /> (For Non-Transferable,-Revocable,and Suspendable) <br /> ENVIRONMENTAL_ HEALTH-PERMIT SEPTAGE <br /> LIQUID WASTE <br />' Application is herebyruAftto Arryon business in the jurisdictionai area of the SanlDa uin.L Health Di tj'ict <br /> r F N Business e ( A) P" _Address � � <br /> z Owner_ Address <br /> Firm Partners, Addresses and Telephone Numbers )--� <br /> aBusiness 7Telephone No. Emergency Telephone No. <br /> Contractor Licence No. f <br /> L Applicants Name (Print) <br /> Please check A Title - <br /> Applicable Cate o _ <br /> PP g ry (1-7)and Fill in the Required information Date�. - ,� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGIS ? 3 <br /> REGIS'T'RATION (FOR EACH VEHICLE) I <br /> For July 1, June 30, 19 Disposal Sites d <br /> Description(Make/Yr., Color) I • <br /> Serial No. } CAL. License No. _r . CAL. License Renewal No: <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address ` I' i <br /> 2. ❑ PUMPER YARD: t <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored filr. <br /> 3. ❑ PERCOLATION TEST 1 I <br /> R.S. or R.C.E. Name +. <br /> } R.S. or R.C.E. No. �° ) <br /> Test Location Test Date/Time !I� <br /> 4. ❑,SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> J4 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE Pi_T ❑rOACKAGE PLANT i; \ <br /> 'Cl PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR '❑ OTHER I <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site s f" <br /> No. of Units '1 <br /> Equipment Storage/Cleaning Location(s) ,I <br /> 6. 0 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 " <br /> Operator Name ? Where Certified' <br /> Plani Location i . <br /> Plant Capacity = No. Units Served <br /> f <br /> 7° ❑ LAUNDRY For July'1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. r i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.' <br /> S; <br /> in <br /> in Such Manner d5 tQ se hECOFP gi!J!EC9 nafv,8a�:rtifo- #11 frltcwitsr- 'j{ rt f h ' <br /> ri�r rear yt trrthepe;F�rmanrwaft`eivorf�forivhiahtnisperrrit;slssued.l !1 t jlsorl+< r Ca lnofe npfoyany <br /> p, a� r. E'i�)j L'ii.:'J•'.:v -' i t'' <br /> • ' prep <br /> e r't'iii, - - - ru'ir.i, :i.!1..,,i ::1C'iJCIX f0,iJil!Ctl;i1iS r�;i;,,is''�;lgra + <br /> I hereby certify that I have prepared this applicafi2in and that the work will be done in accordance with San Joaquin Gouhty11`tll <br /> ordinances, state laws, and rules regulations of�the S Joaq p Local Health Dis'Pct. <br /> APPLICANT'S SIGNATUREX ARA, y /� / T <br /> ' -FOR DEPARTMENT USE ONLY <br /> Fee Is Due; ❑ ANNUALLY ❑ PER U'1 ❑ PEfi SITE ❑ EACH ❑ " <br /> January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE <br /> 'BASE_ EXPLANATION BILLING REMITTANCE - # $ REMIT <br /> .14 DATE D TE REMITTED_- - AMOUNT DUE CHECKED,- <br /> FEEAMOUNT !� <br /> - j <br /> 4, <br /> t <br /> LESS <br /> PRORATION— .. <br /> PLUS .I <br /> PENALTY - - <br /> .OTHER ,f <br /> OTHER <br /> li <br /> eceived 159 Datept A �I <br /> Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO.' ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E-HAZELTON AVE-,P.O.eo.2069 STOCKTON,CA 95201 '"' <br /> II <br />