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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> .. APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE i <br /> Applicatio i hereby ade to carry on b siness in the jurisdicti nal area of the``S�a�ri Joaquin Local Health District <br /> rn Business Name (DBA) -Add ress� L�{ <br /> 1 <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses an Telephone Numbers <br /> M <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 7 <br /> LApplicants Name (Print} Title Date <br /> Please check Applicable Category (1-7)and Fill irghe Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) W <br /> For July 1, June 30, 19 Disposal Sites I <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Lic:.nse Renewal No. <br /> Capacity Gal., Weights & Measures No. 0' <br /> Equipment Parking Address <br /> I <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 II <br /> n <br /> No. of Vehicles Stored _ 1 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST f <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 <br /> Job Address/Location L <br /> Owner Address <br /> '❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW T ❑ REPAIR OTHERf��� � _ y� <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning_Lpcation(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 rules and regulation of the San Joaquin Loa Health District. y <br /> APPLICANT'S SIGNATURE X <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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 57 < <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER / <br /> OTHER <br /> I <br /> E <br /> Received by Date Receipt No. Permit No. Isspanef Date Mailed Delivered <br /> APPLICANT�RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTO C� - <br /> I <br />