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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> II APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> it ENVIRONMENTAL HEALTH PERMIT SEPTA_GE <br /> LIQUID WASTE <br /> Applicateriaby made arry on iness in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) Address <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No, <br /> Contractor Licence No. <br /> L 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) <br /> For July 1, _ June 30, 19 II 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 il' ) <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name :i R.S. or R.C.E. No, <br /> Test Location " Test Date/Time <br /> 4. ❑ SANITATION PERM T <br /> Job Address/Location <br /> Owner Address o <br /> ❑ SEPTIC TANK • ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ,❑�PACKAGE PLANT �~ <br /> ❑ PERMANENT ❑ TEMPORARY 11 NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site V <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 <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, and rul gala' s ofn J a is rlc . <br /> APPLICANT'S SIGNATURE X <br /> , j <br /> It. FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Peceived By January 31 ❑ July 1 &Received By July 31 <br /> REMET <br /> BILLING REMITTANC $ <br /> RASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> d s5 !( 1 B Alps/ $ <br /> Received by Date Receipt No. Permit No. Is rice ate M e Delivered <br /> APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PEFiMIT/SERVICES .1601 E.HAZELTON AVE.,P.O.-Box 2009 STOCKTON,CA 95201 <br /> F <br />