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Applications Will Be Processed When Submitted Properly Completed. Be Sure <br /> To Sig The Application:.. <br /> ..A�. APPLICATION <br /> ` , ' ��}(For�Non-Transferable, Revocable;"and Suspendable) �- t <br /> /ykENVIRONME'NTA'L`rIEALTH,P`ERMIT SEPTAGE <br />.� lJ LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin_Local Health District <br /> F Business Name(DBA) <br /> . , <br /> '�Address <br /> aOwner <br /> -^ .-. Address _ . <br /> j Firm Partners, Addresses and Telephone Numbers E. -" <br /> aBusiness Telephone No. Emergency Telephone No.. v v <br /> Contractor Licence No. ' <br /> L Applicants Name (Print) J <br /> Title 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 1`- , . a Disposal Sites <br /> Description(Make/Yr., Color)-------------- <br /> Serial No. _ CAL. License No. CAL. License Renewal NO. <br /> Capacity '3 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 ror <br /> R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/ cati n � Ate <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL [],,LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT - ; <br /> ❑ PERMANENT ❑ TEMPORARY ❑,NEW El REPAIR t OTHER <br /> 1 <br /> 5. 13 CHEMICAL TOILETS For July 1,f une 30, 19 r <br /> Type Construction i Disposal Site ' <br /> .' <br /> No. of Units Equipment Storage/Cleaning Location(s) + <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t <br /> Operator Name 4 Where Certified b <br /> Plant Location <br /> Plant Capacity No. Units Served F s i' <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 - A8 <br /> SIZE: ❑ Less Than 1,000 Sqw Ft., ❑ More Than 1,000 Sq. Ft. , <br /> ❑ DRY CLEANING, Chemicals Used/Amo iunt/Mo. i <br /> i <br /> in suchetas►ooyri+aeartotobW4aYMrt'saiyr�tu+a�rrl�ashlalGltewiti�:.,lpert. fihatelltAt�et�ttlr�tNr>�tdcAlht! � <br /> tT�aeneprtssuNftitowatl mm'scp�tleafjelsof> rtia.• perinftis�uer.JsPe�tMNampiayaaypersen <br /> lotsiar �c4r + tTon3+awsa4Catitarnist } <br /> t#at�nu �ftwm*lot thpemitw3aud,Ishall <br /> employ <br /> pers Rsgubjctoftrkn►asgoft"" t� <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 regulations of'the San Joaquin Local Health District. I. <br /> APPLICANT' TURF�(�� I. <br /> ' FOR DEPARTMENT USE ONL <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑-January 1 &Received By January 31 ❑ July 1 &'Received By July.31 <br /> BILLING REMITTANCE. REMIT <br /> BASE EXPLANATION -" " $ �' -wd AMOUNT OUE J CHECKED <br /> i, DATE K DATE REMITTED "$ AMOUNT <br /> FEE <br /> LESS <br /> z Y <br /> PRORATION s <br /> PLUS c <br /> PENALTY - <br /> OTHER- <br /> OTHER <br /> THER-OTHER e 7 <br /> Received by Date 'Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2000 STOCKTON,CA 95201 <br />