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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 /> T ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> �~ <br /> LIQUID WASTE <br /> Application is hereby de to car bu i s in the jurisdictional area of the Sig Jr,�aq Local HQalth Pkqtrict <br /> F rn Business a (PBA) Addres <br /> a Owner A r/ss <br /> Firm Partners, Addresses and Telephone Numbers <br /> mo 00P A, <br /> 71 <br /> aBusiness Telephone No. 36T 3!F3` Emergency Telephone No + u- y <br /> Contractor Licence No. <br /> L Applicants Name (Print) 1 L Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information 0 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) __z <br /> l 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. <br /> Equipment Parking Address <br /> I 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> x No. of Chemical Toilets Stored <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 /> L 4. SANITATION PERMIT�7` <br /> Job Addr Location E� <br /> Owner . Address u <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑� SEEPAGE PIT 11 PACKAGE PLANT <br /> ,PERMANENT ❑ TEMPORARY 11 NEW �—REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ' <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> I 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 /> r <br /> 1 <br /> I hereby certify that I have pr red this ap ation a d that the work will be done in accov9 a with San Joaquin County <br /> 11 <br /> ordinances, state laws, a and reg <br /> ula s an Joaquin Local Health District.[ <br /> APPLICANT'S SIGNATURE X b <br /> FOR DEPARTMENT USE O 'L <br /> Fee IS DUB: ❑ ANNUALLY ❑ PER UNIT 11 PER SITE ❑ EACH ❑ Ja rhe &Received By January 31 © July 1 &Received By Juky 31 <br /> BILLING RE IT NCE <br /> { BASE' EXPLANATION AMOUNT DUE CHECKED <br /> DATE AT REMITTED AMOUNT <br /> I -.. - D'� <br /> k FEE � <br /> t LESS <br /> PRORATION <br /> PLUS <br /> { PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date, Receipt No. Permit No. Issuance ate I Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO:' -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601-E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />