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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 /> l' LIQUID WASTE <br /> Applica ion is h eb m d to car on bu inpss i he'uris i t, al area of th San quin o I Heal D'stric t <br /> y Busines Name {DBA} ddress <br /> zOwner '� r'- � Address <br /> J Firm Partners, Addresses a Tie hone Numbers <br /> E. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) "' ALLTitle 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. i <br /> Capacity _ Gal., Weights & Measures No.,- <br /> Equipment <br /> o.,Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> 1 For July 1, . June 30, 19 <br /> F No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> } 3. PERCOLATION TEST <br /> R.S.or R.C.E..S. or R.C.E. Name No._ _ <br /> Test Location I Test DatelTime ' <br /> 4. 11 SANITATION PER t } <br /> Job Addr�s._/.�_o,c tion 99J'S <br /> �A) 11 Address N r 0 <br /> Owner � - <br /> 13-SEPTIC TANK ❑ CESSPOOL �1~ACHING FIELD SEEPAGE PIT ❑'PACKAGE PLANT <br /> 11'PERMANENT ❑ TEMPORARY ° 11 NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site z <br /> -'Type Construction Dis p <br /> } <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> B.�{❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> i Operator Name Where Certified <br /> M Plant Location 5 t fi <br /> �. Plant Capacity No. Units Served -- <br /> 7'313 LAUNDRY For July 1, -June 30, 19- <br /> SIZE: <br /> 9 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r, x <br /> I hereby c haat I have prepar this applica n and that the work will be done in accordance with San Joaquin County .. <br /> i ordinances, tate la and ru s reg do s f the n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> IFOR 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 /> BILLING REMITTANCE $ ,AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> rPLUS <br /> PENALTY ' c <br /> OTHER <br /> r 4 -- <br /> �- *'?' `OTHER-�.,� ..-._...�..----�„--^^ —.T ,,..,,,..->..-.�....ar,eai.e•-...Vie.- -=R--•- -,...-.,.-�. ...._ - .«... ,yeses; <br /> _ Received by ate Receipt o. - Permit No., I s ante ate Mailed Delivered,,, <br /> APPLICANT—RETURN ALL COPIES TO:I[ ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2 ON AVE.,P.O.Box 2009 STOCKTON,CA 95201 � <br />