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r Applications Will Be Processed When Submitted Properly Completed, Be�SureTosign Inerippllca++u++• <br /> i APPLICATION <br /> arc '(For Non`-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE �,�ji <br /> A licatio s hereby mlet,�ear buss ss in the jurisdictional area of the San Joaq 'n Lo al Health Distric � <br /> yBusiness �ame (DBA} Address,/oX333 <br /> z Owner Add ss <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> f a Business Telephone No, Emergency Telephone No. <br /> I a - <br /> Contractor Licence No. <br /> Applicants Name (Print) <br /> Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites F <br /> Description(Make/Yr., Color) f I <br /> Serial No. CAL%License No. I- -- CAL. Licznse Renewal No. ` <br /> Capacity Gal., Weig is &Measures No. ! n <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 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name I R.S. or R.C.E.Na <br /> I Test Location Test Date/Time - <br /> 4. ❑ SANITATION PERMIT <br /> 251. w- . - A- G 3 � <br /> Job Addr ss/LocationrZ <br /> rOwner` v Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑}SEEPAGE PIT ❑ PACKAGE P ANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR 13 OTHER <br /> � <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site. <br /> r <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 11PACKAGE TREATMENT PLANT. For July 1, -June 30, 19 I '� <br /> Where Certified <br /> Operator Name <br /> � I <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 _ ( r <br /> I SIZE: ❑ Less Than 1,000 5q. Ft., i❑ More Than 1,000 Sq. Ft. <br /> " <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i� <br /> t p <br /> t <br /> I hereby certify that 1 have repared this application and that thew k will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rules and regulati of Jo Local ealth District. :r r; <br /> k <br /> I' <br /> APPLICANT'S SIGNATURE _ <br /> ht _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH',_ ❑ January 1 &Received By-January 31 E3 July 1 &Receivedli8y July 31 <br /> REMIT <br /> SASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATEDATE REMITTED AMOUNT <br /> FEE <br /> 5 f <br /> LESS <br /> PRORATION 1. <br /> V <br /> PLUS .' <br /> PENALTY <br /> 6 I <br /> i OTHER <br /> 4 OTHER P <br /> r D �w <br /> Received by a Receipt No. Permit No. Issuance Date Mailed Delivered . <br /> .. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 952 <br /> s _ ii <br />