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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION F <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE � <br /> Application her y mad o car on bust ss in the' sdictional area of the Jq@ 1 cal I istri /] <br /> rn Busine am (qBA) Addr s <br /> s <br /> a Owne i Address <br /> J Firm Partners, Addresses and Telephone Numbers ! r_ - I / <br /> Q. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. ,Y 7.Ar / od <br /> L Applicants Name (Print) GC 6 Title CA_ Date ep` s`X,-, i <br /> Please check Applicable Category(1-7)and Fili in the Required Information I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ` i <br /> For July 1, . June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc,se Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored j <br /> .No. of Chemical Toilets Stored } <br /> 3. ❑ PERCOLATION TEST i <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Lcati n <br /> Owner Address � E- <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> M--P'ERMANENT ❑ TEMPORARY ❑ NEW 9-NEPAIR ❑ OTHER J <br /> 5. [1 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site j <br /> No. of Units Equipment Storage/Cleaning Location(s) j <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t/ <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑, LAUNDRY For July 1, -June 30, 19 <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 appl+icatio and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r a regulations h 5 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 January 31 ❑ July 1 S Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE s'{ L4 <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY i <br /> OTHER I <br /> I <br /> o - <br /> OTHER <br /> � f <br /> Received by Date c. Receipt Np. Permit No. Issuance ate Marletl Delivered <br /> ,,.Y APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA P5201 i <br />