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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> f APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) N" <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE [ <br /> Applicatio I h r y e to rry on b ess' jurisdictional area of the San J i ca He�It _iStri <br /> y Busines {D)�A ddress <br /> aOwner Address <br /> Firm Partners, Addresses an T lephonn Numbers l <br /> aBusiness Telephone No. Emergency Telephone No. <br /> I _J Contractor Licence No. —71 7.2 <br />, a <br /> i L Applicants Name(Print) Title 'L! Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <br /> Serial No. CAL. License No. CAL. License 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 <- <br /> E _ <br /> No. of Chemical Toilets Stored - <br /> . <br /> i 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name - S. or-R.C.E. No.-, <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT �'- �-- <br /> Job Addres cation <br /> Owner Address '3ef-p— <br /> WSEPTIC TANK ❑ ESSPOOL &ILEACHING FIELD 3-'TEEPAGE PIT ❑ PACKAGE PLANT <br /> ERMANENT ❑ TEMPORARY ❑ NEW B�IEPAIR ❑ OTHER <br /> 5. El CHEMICAL TOILETS For July 1, -June 30, 19 <br /> n <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., EI.More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/,tMo. <br /> �` <br /> I hereby certify that I have prepared thisapplica ' d t t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r and r ulations S _Joaquin Local Health-District. I <br /> } <br /> APPLICANT'S SIGNATURE X ; <br /> ` FOR DEPARTMENT USE ONLY - <br /> Fee IS Due: ❑ ANNUALLY El PER UNIT y.❑,.PEB_SITE.,.,_,.,.©_EACH.,.,,._€ ,❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 'r REMIT <br /> SASE EXPLANATI�ON BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ` r r DATE DATE REMITTED AMOUNT <br /> FEE ,$ V.� - �' <br /> LESS <br /> PRORATION -_-- <br /> PLUS J. f <br /> PENALTY <br /> OTHER . .--Z <br /> OTHER <br /> 4 <br /> Received by Date Receipt No. 'Permit No. Issuari a Date Mailed D.I.r,d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O,Box 2009 STOCKTON,CA 95201 y <br /> 7 <br />