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'Applications Will Be, v _ ftted Properly t 1pleted.Be Sure To Sign The Application. t <br /> APPLICATION r <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application 's hereby de to carry siness,in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Na ems ° Address <br /> Owner Address <br /> Firm Partners, ddresses and Telephone Numbers <br /> a.Business Telephone No. _ 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 Information C> <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHMLE) <br /> For July 1, June 30, 19 D. OS4 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 Location :Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Loc. 'on 7 , <br /> Owner Address <br /> SEPTIC TANK CEAeP&0L 11LEACHING FIELD ❑ S PAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEWREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 —" <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 /> Plant Location v <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1; -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than4,000 Sq. Ft: <br /> DRY CLEANING,Chemicals Used/Amount/Mo. ' <br /> r <br /> I hereby certify th%.I have prepgredp ) cation and that the work will be done in accordance with San Joaquin County <br /> ordinances,state IaV, a d u es atins 'of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> 40R DEPARTMENT USE ONLY # <br /> Fee IS Due}.❑ ANNUALLY ❑ PER UNIT ❑ SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> O <br /> s 'BILLING REMITTANCE $ REMIT <br /> BASE E �IVPl AMOUNT DUE CHECKED <br /> AT[ <br /> ;. DATE DATE' REMITTED AMOUNT <br /> c <br /> FEE <br /> LESS ` #_ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> f <br /> rev <br /> OTHER <br /> OTHER <br /> GL <br /> Received-by Date Receipt No. Permit No. Issuance to ffiled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ,'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E:HAZELTON.AV ., . x 2009, STOCKTON,CA 95201 <br />