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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ~: APPLICATION <br /> T (For Non-Transferable, Revocable, and Suspendable) <br /> ., <br /> r ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i er, y mad to rry o busin ss' the' 'sdictional area of the S JoaqUin Local Health Dista t <br /> i N Business Name (D A) Address <br /> aOwner Address <br /> 3 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> J Contractor Licence No. 2—.2— _ , <br /> L Applicants Name (Print) Title Date 4 <br /> Please che:&WApplicable.Gategory(1-7) and Fill in the Required t rmation <br /> 1:,,❑;;,PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) a <br /> For July 1, June 30, 19e!b Disposal Sites <br /> -Description(Make/Yr.;Color) <br /> Serial No. Ip CAL. License No. CAL. Licc-lse Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address I� <br /> 2.' ❑ PUMPER YARD <br /> For July 1, June 30, 19 , <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored .a <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Ip Test Date/Time <br /> 4. ❑ SANITATION PERMIT I <br /> Job Address/Lo tion <br /> Owner <br /> Address <br /> ❑ SEPTIC TANK ❑ SSPOOL ❑ L CHING FIELD ❑ ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ EMPORARY ❑ NEW EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Q <br /> Type Construction �M Disposal Site <br /> No. of Units ! Equipment Storage/Cleaning Location(s) <br /> yh <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 fes; <br /> Operator Name i� Where Certified 1' <br /> � I` <br /> Plant Location I <br /> Plant Capacity IM No. Units Served <br /> 7. ❑ LAUNDRY For July 1, JlJune 30, 19 <br /> SIZE: 11 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft: <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify thatj�l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and egulations of the n oaquin 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 January 31 ❑ July 1 &Received By July 31 <br /> I REMIT <br /> tI BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> k <br /> LESS <br /> I-OCT <br /> PRORATION <br /> PLUS r <br /> PENALTY h' <br /> OTHER <br /> OTHER '� _ of <br /> 3 S a T' <br /> Received by Date Receipt No. Permit No. kssuance Uate Mailed Delivered <br /> -APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 20D9 STOCKTON,CA 95201 <br /> 11 z <br />