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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 /> 1 i LIQUID WASTE <br /> w Application is y m rry on usiness in the jurisdictional area of the San Joaquin Local Health <br /> Business Name (DBA)�� Q�• Address I' l37d"� ���0 <br /> aOwner Address <br /> J Firm Partners, Addresses and lephone Numbers <br /> m Business Telephone No. �� �07 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) D Title CC r Date 7a <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. Licc,rse 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 Location Test Date/Time <br /> 4. Xi SANITATION PERMI��� <br /> Job Addre Locati n <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSP OL �K LEACHING FIELD K SEEPAGE PIT ❑ PACKAGE PLANT CA <br /> PERMANENT ❑ TEMPORARY 119NEW REPAIR ❑ OTHER C/) <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 U <br /> Type Construction Disposal Site <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 /> a <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. ,A <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, a 211rules and r gulatio f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DA E REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE U� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER S <br /> OTHER <br /> 0 �B (Q�s�o--ED <br /> Received by Date Receipt No. Permit No. Issuance 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 />