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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. \—(T� <br /> APPLICATION ,' <br /> r (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) Address <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <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. Liccnse 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/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ 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 <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 /> b <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 and regulations of 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 T&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION — <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receivedf Date Receipt No. Permit No. Issuance Date Mailed Delivered 'Yti <br /> APPL_'✓ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,.P.O.Box 2009. STOCKTON,CA 96201 <br />