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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 /> LIQUID WASTE <br /> Application is her ma to c rry o sines in a jurisdictional area of the 5 oagyyn Loc ealth trict /) <br /> m Business N DBA) , Add �� r _ <br /> a Owner l C Address ��� lax <br /> Firm Partners, Addresses and Tele hone Numbers I CjG <br /> aBusiness Telephone No. 3 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) e �1 Title <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 Juiy 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.G.E. No. <br /> Test Location Test Date/Time j <br /> 4. SANITATION PE !J <br /> Job Address/Location —/4p.2 <br /> Ownera+✓► (Ip Address ��L <br /> ErSEPTIC TANK C1CESSPOOL LEACHING FIELD EI SEEPAGE PIT PACKAGE PLANT <br /> 19-PERMANENT ❑ TEMPORARY 9-nEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 1�_ <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) l <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 '4 <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 /> I hereby certify that I h repay this ap t' and that the work will be done in accordance with San Joaquin County <br /> ordinances, state law nd rul nd regul the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> J <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 /> BILLING RFMITTANCE" $ REMIT <br /> BASE EXPLANATION DATE HATE REMITTED AMOUNT DUE CHECKED 3 <br /> AMOUNT <br /> FEE r <br /> LESS � 1 <br /> PRORATION } <br /> PLUS <br /> PENALTY <br /> OTHER ( Q <br /> OTHER I <br /> M <br /> Received by Date Receipt No. Permit No. issuance unto Mailed 'Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.-Box 2009 STOCKTON,CA 95291 <br /> � r <br />