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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 /> f ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> r <br /> K LIQUID WASTE <br /> Application is ereby�made to c rry n business in the�r'�sdiional area of the San Joa uin Local Health Dista tBusiness Name DBA) iP50 <br /> Address <br /> a OwnerAddres <br />�. Firm Partners, Addresses and Tele one Nu ers s <br /> COL' Business Telephone No. Q Emergency Telephone No. <br /> Contractor Licence No. 2 <br /> �Applicants Name (Print) It <br /> Title Date '` <br /> Please check�Applli:able Category (1-7) and Fill in the Required formation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; i 'June 3019 Disposal Sites <br /> Description(Make/Yr., Color). it <br /> Serial.No.,- * 4 �?� 1 CAL. License No. CAL. License Renewal No. <br />: ._, <br /> Capacity - �11 '>;- � Gal., Weights & Measures No. <br /> e *. � • rh $ <br /> Equipent Parking Address' <br /> 7 PUMPER YARD" <br /> Ff June 330 9 <br /> M <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.G.E. No. <br /> Test LL tion Test Date/Time { <br /> 4. IEf SANITATION PERMIT <br /> Job Addyegs-Location <br /> Ow r Address <br /> , PTlC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> Ifs PERMANENT ❑ TEMPORARY ❑ NEW PAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> _Type Construction Disposal Site <br /> No. of Units E ui•Equipment Stora Storage/Cleaning n Location(s) " <br /> q P y 9 g - <br /> 6. 13 PACKAGE TREATMENT PLANT For Jul 1, -June 30, 19 I} " <br /> Operator Name � 4 Where Certified Ot <br /> Plant Location <br /> Plant Capacity No. OLhitsServed t.N It <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 SgFt. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. a <br /> I hereby certify that have prepared this pplication and that the work will be done in accordarAe with San Joaquin County �. <br /> ordinances, state laws, and rules and ula <br /> regtions of the <br /> &A Joaquin Local Health District. L� <br /> APPLICANT'S SIGNATURE X <br /> ri <br /> _ FOR DEPARTMENT USE ON <br /> Fee Is Du-e: ❑ —ANNUALLY'—[ PER UNIT ❑ PER SITE ❑.EACH• Janu ec ived By January 31 ❑ July 1 R Received By July 31 <br /> BASE EXPLANATION BILLING REMIE $ REMIT - _ <br /> DATE AMOUNT DUE, CHECKED . <br /> ' <br /> D REMITTED <br /> FEE <br /> AqS "' <br /> AMOUNT <br /> �7 b <br /> LESS k� <br /> PRORATION; <br /> PLUS <br /> PENALTY r' <br /> OTHER r �- <br /> ,_.i • <br /> OTHER f <br /> a <br /> Received by Date Receipt No. Permit No. Iss n e ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES'TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201 <br /> r mow; <br />