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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati n is here ade to car o usiness in the jurisdictional area of the San Joaqul Local Health stri <br /> Business Name (DBA) Address_. <br /> z Owner Address <br /> a <br /> J Firm Partners, Address n Tel phone Numbers <br /> CL Business Telephone No, Emergency Telephone No. <br /> a <br /> � <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) s I <br /> For July 1, June 30, 19 Disposal Sitesl <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 i <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets Stored t # <br /> 3. ❑ PERCOLATION TEST .t _ ,, + a <br /> R.S. or R.C.E. Name' R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PER C <br /> Jab Address/ ocation Les r IF <br /> caner <br /> SEPTIC TANK y❑�CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT !!, . ,TEMPORARY kNEW REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction, f 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 ' Y <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. <br /> t <br /> I hereby certify that I have prepared this application and that the7 work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulati of the San Jo in ocal Health District. y <br /> APPLICANT'S SIGNATURE X <br /> e FOR DEPARTMENT USE ONLY r <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 B Received By January 31 ❑ July 1 a Received By July 31 <br />� <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS C�l <br /> PRORATION V ,,•�"7 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -- X3_3 <br /> Received by Date Receipt No. Permit No. Issu ce ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />