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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Z? APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appl icatio reby made t c ry n bu in the' r' i io area of the an oaq 'n Local Health Dis t� <br /> Business Name BA ` dress <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone umber <br /> 0. Business Telephone No. 211"q j-j 6-5 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) - Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Aformation <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. 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 /> 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 LL ation Test Date/Time <br /> 4. L� SANIT ION PERMIT <br /> Job Addres /Loc do <br /> Ow r Address <br /> ,��- D �� <br /> PTIC AN ❑ CESSPOOL rEACHING FIELD St E PIT ❑ PACKAGE LANT <br /> L� PERMA ❑ TEMPORARY W PAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site Tt <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 /> 0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance withfS gJoaquin County <br /> ordinances, state laws, and rules an regulations of the J quin Local Health District. <br /> APPLICANT'S SIGNATURE X 10/ t <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &ReEe`iV29'By January 31 ❑ July 1 &Received By July 31 <br /> ,! REMIT <br /> BILLING REMITTANCE " $ <br /> BASE EXPLANATION DATE DATE 4. 'AEMITTED AMOUNT DUE CHECKED <br /> t�C� AMOUNT <br /> FEE 1zJO� 3a' � �50 <br /> LESS <br /> PRORATION t, <br /> PLUS <br /> PENALTY <br /> OTHER *� <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issu nce 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 />