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Applications Will Be Processed When Submitted Properly Completeo. tie ours rai ...n• ' <br /> APPLICATION <br /> f (For Non-Transferable, Revocable,and Suspendable) SEPYAGE I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> y Address <br /> Businesse DBA) 2 �� Address <br /> a Owner <br /> Firm Partners, Addresses and Telepho�]e Nurn�ers Emergency Telephone No. <br /> aBusiness Telephone No. .� ' !,G <br /> Contractor Licence No. Title Date _ <br /> LApplicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR oEACH <br /> teVEHICLE) <br /> DisFor July 1, June 30, 19 <br /> Description(Make/Yr., Color) CAL. License No. CAL. Licz.nse Renewal No. <br /> i Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity 1 <br />_ Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> t. <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> ` 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.G.E. Name Test Date/Time <br /> Te!t Location , <br /> q. SANITATION PERMIT <br /> Job Address/ ca 'on Address <br /> WQwnerp (� PACKAGE PLANT <br /> ETIC TANK CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ^� �,[� <br /> F ❑ TEMPORARY 9NEW ❑ REPAIR OTHER•,y �S C� "J N <br /> PERMANENT <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> ` <br /> Disposal Site <br /> Type Construction <br /> i <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified �— <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> l 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 ha re . -this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, Ind gulations o e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> L <br /> ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July f &Receiv July <br /> 31 <br /> Fee Is Due: ANNUALLY REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> SASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE _1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> E PENALTY <br /> OTHER <br /> OTHER <br /> Receipt No. Permit No. Issua <br /> /SERVICES nce Date Mailed Delivered <br /> f ceived pate by 1601 E.HAZELTON AVE.,P.O.Box 2009_ STOCKTON,CA 95201 <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT <br />