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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. so <br /> I APPLICATION <br /> (For Nott-Transferable, Revocable, and Suspendable) <br /> I <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br />� LIQUID WASTE <br /> AID plicatio I h eby ma carnibn busin in the jtfrisdictional area of the San Joaquin Lac He D' tri <br /> y Business Name {DBA Addre e' <br /> aOwner Address DS <br /> ff Firm Partners, Addresses and Telepho a Numbers <br /> I a. Business Telephone No. �� — Emergency Telephone No. <br /> Contractor Licence No. ej0 en <br /> Applicants Name (Print) Title r Date ;eo <br /> Please check Applicable Category (1-7)and Fill in the Requir d 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. License Renewal No. <br /> Capacity 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.G.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. R'SANITATION PERMIT a <br /> Job Addretss,//L�ocattion Jw" <br /> Owner //,!l/+�� 1� Address a ©fin <br /> ❑ SEPTIC TANK ❑ CESSPOOL KLEACHINGFIELD 7SEEPAGEPIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER Q <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 i <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity 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. <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 rules and repul ions of t1W San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31. ❑ July 1 &Received By July 31 s1 <br /> BILLING REMITTANCE $ REMIT i <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED a <br /> �( AMOUNT , <br /> FEE q S - —1 S <br /> LESS <br /> PRORATION r� <br /> PLUS <br /> I PENALTY <br /> OTHER r <br /> OTHER <br /> 0_�3S`-{ ro f;t i 8a <br /> Received by Date Receipt No. s*Permit No Ess ance Dae Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601'E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - •`� <br />