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Applications Will Be Processed When Submitted ProperlyCompleteO. tiesure io atgn IneKppuanuv,r. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio her�by�mad carry usine In the juH�dictionak area of the San Joaquin al eat D' r t <br /> NBusiness �%�ame (D A) Addr <br /> I- <br /> Owners <br /> Address_/ 7_0 <br /> U Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 3 G <br /> � <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill i the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 'I, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc tse Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PIIMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored v <br /> 3. ❑ PERCOLATION TEST 1t�`ir <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. g SANITATION PERMIT <br /> Job Address/ ocation Q <br /> Owner�/ Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 19 SEEPAGE PIT ❑ PACKAGE PLANT 0 <br /> PERMANENT ❑ TEMPORARY ❑ NEW V REPAIR ❑ OTHER Q <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 C <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 ;,LEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, les and r gul tions of tan Joaquin Local Health District.ei <br /> S p <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fire Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED !yf AMOUNT <br /> FEE <br /> LE=SS <br /> PRORATION r <br /> PLUS <br /> P17NALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No- I suance Date ail Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> �J <br />