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W m Applications Will Be Processed.When Submitted Property Completed. BeSure Io a1911 1• ^r <br /> APPLICATION <br /> (For Non-Translerable, Revocable,and 5uspendable) SEPTAGE <br /> ,v <br /> ENVIRONMENTAL�H STE TH PERMIT <br /> LIQUID <br /> r <br /> Application is hereby made to carry on b siness in the jurisdictional area of the San Joaquin <br /> Scal Health District <br /> y <br /> Address <br /> NBusiness Name (DBA) Address <br /> aOwner <br /> J Firm Partners, Addresses and Telephone Numbers <br /> mbers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> a Contractor Licence No. Title L Date ? <br /> �, <br /> LApplicants Name (Print) �f <br /> in the Required Information <br /> Please check Applicable Category (1-7) and Fill C> <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOREACH <br /> VEHICLE) <br /> For Julp, June 30, 19 Disposal <br /> Description(Make/Yr., Color) CAL License No. CAL. License Renewal No. <br /> a <br /> Serial No. , <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2• ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> l No. of Chemical Toilets Stored <br /> I 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> i <br /> Test Location. <br /> 4. SANITATION PERMIT <br /> Job Address/ a n Address <br /> Owner ❑ PACKAGE PLANT <br /> f ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD [3 SEEPAGE <br /> E PIT ❑ OTHER /3XC&110L0 <br /> ❑ PERMANENT ❑ TEMPORARY NEW rn <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 1plsposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ElPACKAGE TREATMENT PLANT For July 1,-June 30, i9 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7, El LAUNDRY For July 1, -June 30, 19 More Than 1,000 Sq, Ft. <br /> 1 SIZE: ❑ Less Than 1,000 Sq. Ft., <br /> r ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 4 <br /> L hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I ordinances, state laws, and rutnd gulations of the San Joaquin Loc Health District. <br /> APPLICANT'S SIGNATURE X <br /> G <br /> FOR DEPARTMENT USE ONLY <br /> REMIT <br /> ved By July 31 <br /> Fee IS Due: ❑ ANNUALLY PER UNIT PER SITE ❑ EACH ❑ January 1 8.Received By January 31 ❑ July 1 8 ReceiCHECKED <br /> BILLING REMITTANCE $ AMOUNT DUE <br /> I BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE ' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY `x <br /> OTHER <br /> OTHER ((�� ! <br /> Mt� 1 /,3 ate Mailed Delivered <br /> Received by Date <br /> _ Receipt No. Permit N <br /> � �gp7 E.H AVE.,P.O.Sox-2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITISERVICES (� <br />