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- --_ <br /> t <br /> Applications WIII 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 /> Applicatio .is he eb ade to carrA on bus* ss in the j isdictional area of the n aquinI He Distr' N <br /> FBusiness Name (DBA) + �' <br /> I � � Address •�� .��--�, <br /> a Owner Address <br /> J Firm Partners, Addresses and Telphone Numbers <br /> a'Business Telephone No. O Emergency Telephone No. <br /> Contractor Licence No. 3 SL_3 <br /> Applicants Name (Print) ✓✓ 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 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No, J <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 t <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. 'g SANITATION PERM T i <br /> Job Addr s/L cation Z + <br /> Owner Address R' <br /> SEP TANK 11 CESSPOOL LEACHING FIELD g SEEPAGE PIT ❑ PACKAGE PLANT Qo <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units <br /> 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 A <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 prepared this application and that the work will be done in accordance'with San Joaquin County <br /> ordinances, state laws, and rules and r gulati f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH. ❑ January 1 &Received By Januar <br /> - Y 31 ❑ July 1 &Received By July 31 - <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATEDATE REMITTED AMOUNT DUEJ:,CHECKED <br /> AMOUNT <br /> FEE �r <br /> LESS <br /> PRORATION r d <br /> PLUS <br /> PENALTY 2 � <br /> OTHER <br /> OTHER <br /> 6 -7 q Fa <br /> Received by Date Receipt No. Permit No - . Iss ance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH.PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 952 <br /> r ��� <br />