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v Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION ` <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) � i Addressb <br /> aOwner % Address <br /> J Firm Partners, Addresses aIT le hone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> I <br /> Applicants Name (Print) Title m Date I <br /> j Please check Applicable Category(1-7)and Fill in the Required Information { <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <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 /> I 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 /> No. of Chemical Toilets Stored .r <br /> 3. ❑ PERCOLATION TEST <br /> I R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT b� t <br /> Job Addre Location <br /> Owner Address I _ <br /> I.SEPTIC TANK ❑ CESSPOOL % LEACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ' 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) 5' <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: [A Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo,' ` <br /> I hereby cerci y th have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rules an �Iatiot San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> , I <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY Cl PER UNIT ❑ PER SITE 0 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION <br /> BILLING' REMITTANCE $ REMIT DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER -7 <br /> Received by Date Receipt No. Permit No. Issuance D to Mailed Delivered ] <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE-.,P.O.Box 2009 STOCKTON,CA 95201 !} <br />