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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 /> f ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> a Application is rebyrmade iQ carry on businesq in the junsdi tion-al area of the San Joaquin Local Health District <br /> f w Business Name ( A) c 2! < J'�C! Address 00"f' e`er <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �.a' Emergency Telephone No. <br /> Contractor Licence No. $ •z- <br /> LApplicants Name (Print) Title Date `�� --Z2 - ?� Q� <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I For July 1,I June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> I Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity s 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 /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test L ation Test Date/Time <br /> 4. 1!3 SANITATION PERMIT <br /> Job Address/ cation— <br /> Owner— <br /> Address <br /> ation <br /> Owner Address <br /> 11 SEPTIC TANK ❑ P CES OL LEACHING FIELD ❑ SEEPAGE PIT ❑ 13ACKAd PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR El 'OTHER 0 <br /> 5. El CHEMICALTOILETS For July 1,--June 30,r19 <br /> Type Construction .�►, D sposah Site r _ <br /> L <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name V Where-Certified,.- - <br /> Plant Location <br /> Plant Capacity T_ 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. t �' X- <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 and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X � <br /> ) <br /> S <br /> k <br /> FOR DEPARTMENT USE ONLY I <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 4 L4_S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 65sgs 30 • 4 . <br /> Received by Date Receipt No. Permit No. Is nce ate Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. - 1601 E.HAZ L ON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />