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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.��� <br />F APPLICATION <br />(For Non -Transferable, Revocable, and Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br />LIQUID WASTE <br />Application ere0y made c on buess i th 'uri tonal area of the o uin Local Health District <br />U Business Name A Address <br />a Owner <br />Address <br />J Firm Partners, Addresses and Tele hone Numbers <br />IL <br />Business Telephone No. <br />Contractor Licence No. ,. <br />r L Applicants Name (Print) <br />Please check Applicable Category (1-7) and Fill in t e Requir d 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. <br />Capacity y 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 />RSorR E N <br />Emergency Telephone No. <br />Title Date _ — <br />k ame R.S. or R.C.E. No. <br />f Test L tion Test Date/Time <br />�4. SANITATION PERMIT <br />Job Address/Loc tion <br />0 <br />L,7Y- Addre s 4 <br />SEPTIC TANK CESSPOOL L CHING FIELD EEPAGE PIT <br />❑ PERMANENT ❑ TEMPORARY I1r NEyy ❑ REPAIR <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction Disposal Site <br />No. of Units ~' <br />Equipment Storage/Cleaning Location(s) <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name <br />Plant Location <br />Plant Ca It <br />pacl y 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. f i <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo... <br />CAL. License Renewal No. <br />U PACKAGE PLANTB <br />13 OTHER <br />If <br />Gy <br />Where Certified - <br />' If <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 rul and regulations of Sa oaquin Local Health District. r <br />•r <br />APPLICANT'S SIGNATURE) <br />FOR DEPARTMENT USE ONLY <br />Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑. January 1 & Received B Januar <br />Y Y 31 ❑July 1 &Received By July 31 <br />BASE .EXPLANATION BILLING REMITTANCE RIT <br />DATE DATE REMITTED <br />AMOUNT DUE C ED <br />FEE <br />fUN'0 <br />LESS �— <br />PRORATION <br />PLUS { <br />PENALTY j <br />OTHER <br />OTHER "Y <br />Received ny Date Receipt No. Permit Na <br />ssuance Uate Mailed Delivered <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERVIT/SERVICES 1601 E. HAZELTpN AVE., P.O. Box 2009 - STOCKTDN, CA 95201 <br />