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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. T <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> `'y �• LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> NBusiness Name A) Address <br /> aOwner X s? a Addrgss <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name(Print) Iot 4 .! R, <br /> Please check Applicable Category (1-7) and Fill in the Required Information 4 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites f <br /> Description(Make/Yr„ Color) <br /> Serial No. CAL. License No, CAL. Licznse 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.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT '56C-3 t�a t Y <br /> Job Address/L � n 1 <br /> Owner ok-, Address <br /> ❑ SEPTIC TANK ❑ ESSPOOL EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLAN <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 N <br /> Operator Name Where Certified <br /> Plant Location <br /> i <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. Y <br /> I hereby certify that I ha prepared this ap kation and that the w rk will ne in accordance with San Joaquin County <br /> ordinances, state laws, 7q.rules and reguWlio s of the San Joaqui Local ea Oi ict. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> O � dQ <br /> PEE � � <br /> LESS lR <br /> PRORATION _ - /� �• (,� ft,(/w� <br /> PLUS <br /> PENALTY f �Q <br /> OTHER <br /> OTHER <br /> Received by I Date Receipt No. Permit Nois��Date Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> r <br />