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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. F <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> G Application 's hereby made to carry on business in the" risdictional area of the San Joa uin Local Health Di s rict <br /> H Business NamZ(D ' <br /> ) - Address ' <br /> a Owner Address --•--�- <br /> 3 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 51/4 S Emergency Telephone No. <br /> Contractor Licence No. 2 Z <br /> t L Applicants Name (Print} j <br /> Title Date <br /> Please check Applicable Category (1-7)and Fill in the Requ ed Information <br /> 1. PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites �Q <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.C.E, Name R.S. or R.C.E. No. <br /> Test Loc6tion Test Date/Time I <br /> 4. SANITATION PERMIT <br /> Job Addre Loc tion <br /> Ower I Address <br /> ® SEPTIC TANK ❑ CESSPOOLLEACHING FIELD + JtEPAGE PIT ❑ PACKA E�PLANT��� <br /> ❑ PERMANENT 0-TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 - 1, <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 <br /> Operator Name Where Certified <br /> Plant Location ° <br /> Plant Capacity No. Units Served h <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 and regulations of the San.Joaquin Local Health District. <br /> f <br /> APPLICANT'S SIGNATURE X ` <br /> 0 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ElANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received,By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> ; <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE � � , r�p <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY 1 <br /> OTHER <br /> OTHER �. <br /> Received tay Date lReceipt No. Permit No. I anc D Mailed <br /> Delivered <br /> APPLICANT 'RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES `1601 E.HAZELTON' E.,P"O.Box 2009 STOCKTON,CA 95201 <br />