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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 /> E ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application rebx made car on busi s in th ju isd' tional area of the 5a qui Local Health Distric <br /> HBusiness Name ( } Address (9714 <br /> z Owner address <br /> 4 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. O Emergency Telephone No. i <br /> Contractor Licence No. I <br /> L Applicants Name(Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Inf anon i <br /> rt 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites i <br /> i Description(Make/Yr., Color) <br /> Serial No. r CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> i Equipment Parking Address <br /> I 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 R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Loc ion <br /> Ow er Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ,��EPAGE PIT ❑ PACKAGE PLANT ; <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 p <br /> l . <br /> Type Construction Disposal Site <br /> No. of Units 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 <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 rule regulations of t San aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Feels Due..[] ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH_ ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> + BILLING REMITTANCE $ REMIT <br /> r BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS l� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER y� <br /> • f C./ <br /> Received byDate Receipt No Permit No. issuance Date Mailed Delivered <br /> t' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009- STOCKTON,CA 95241 _ <br />