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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 /> ENVIRONMENTAL HEALTH PERMIT �'�SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby a to carryo bu ess in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) Address <br /> aOwner Address L �nZJ_ <br /> Firm Partners, Addreslesla'nt Telephone Numbers <br /> CL Business Telephone No. Emergency Telephone No. <br /> a - <br /> Contractor Licence No. <br /> L Applicants Name (Print) 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 " <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Llccnse Renewal No. <br /> i <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address I <br /> 2. ❑ PUMPER YARD b <br /> For July 1, June 30, 19 rt <br /> No. of Vehicles Stored y <br /> No. of Chemical Toilets Stored ) i <br /> I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name 4- R.S. or R.C.E. No. f <br /> Test Location - Test Date/Time <br /> 4. 11 SANITATION PERMIT �� t <br /> Job Address/Location <br /> y1( / <br /> r <br /> Ownerdress <br /> 11 SEPTIC TANK ❑ C SPOOL ❑ LEACHING FIELD ❑.SEEPAGE PIT ❑ PACKAGE PLANT i <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ; `REPAIR ❑ OTHER W <br /> 5. 11 CHEMICAL TOILETS For July 1,-June 30, 194 t <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) _ R' <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. FL, ❑ More Than'1,000 Sq. FL <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> � k <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 rulea and egulati of the San Joaq n Local Health District. . <br /> APPLICANT'S SIGNATURE X <br /> i <br /> .FOR DEPARAFNT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ July 1 &Received By July 31 <br /> -BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED- <br /> AMOUNT I <br /> FEE - '(5 'V .� <br /> LESS <br /> PRORATION <br /> lwlylftl/l A, <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER v <br /> a1 Received by Date Receipt NO. .Permit No. ssuan a Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,,CA 95201 <br />