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t 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 SEpTAGF <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Nam (D A) �i� ' Address <br /> a Owner Address <br /> k Firm Partners,Addresses and Telephone umbers <br /> a. Business Telephone No. — Emergency Telephone No. <br /> Contractor Licence No. a <br /> Applicants Name (Pring Title Yate <br /> Please check Applicable Category (1-7) and Fill in the Required Information �^ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) T <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 /> [t Capacity Gala Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 E <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> a 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 PERMIJ N <br /> Job Address/L Fall n <br /> k Owner Address <br /> I ❑ SEPTIC TANK ❑ CESSPO L LEACHING FIELD k SEEPAG PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY " -LTNEW REPAIR —[]'OTHER " Q <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> C Type Construction Disposal Site (r <br /> No. of Units Equipment Storage/Cleaning Locations <br /> r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> }' Plant Location <br /> Plant Capacity No. Units Se ed <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 /> x <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 r s a ulations of the San Joa uin Local ealth District. <br /> F APPLICANT'S SIGNATURE Xzw— <br /> s ' <br /> I <br /> 3 7-te <br /> FO 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 /> t BASE EXPLANATION BILLING REMITTANCE $ 'AMOUNT DUE CHECKED <br /> DATE DATE REMITTFO AMOUNT <br /> FEE s I <br /> LESS T <br /> PRORATION <br /> PLUS <br /> 11 PENALTY •�Q <br /> OTHER <br /> t <br /> OTHER t fi <br /> Received by I Cate 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 />