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Applications Will Be ProceedWhen Submilled roperly 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 /> Ap'PlIcatigehelebyrria to carry on business in the jurisdictional area of the San Joa n Local Health Distn <br /> HBusiness Nam BA) Address es 2& 7 - <br /> aOwner Address + <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. / Emergency Telephone No. <br /> Contractor Licence No. 1 <br /> 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. 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 L ation Test Date/Time <br /> 4. IQ SANITATION PERMIT <br /> d <br /> Job Address/Locati d <br /> Own Address y <br /> E SEPTIC TANK ❑ CESSPOOL WIL EACHING FIELD ❑ VZ' T 0 PACKAGE PLANT <br /> M/P'ERMANENT ❑ TEMPORARYKNNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30,19 y <br /> Type Construction Disposal Site od <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 j <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 /> 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 rules regulations of the San Joaquin Local Health District: <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY ❑PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1&&ed By July 3i <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT D CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE x <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Ussuarke Datb Mailed Delivered <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />