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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 Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i ereby ma to c rry usine s in a jur' ictionai area of the Sarylya uin al Health District <br /> w Business Name ( A) Address <br /> i Owner <br /> a ddress c _ <br /> L) Firm Partners, Addresses and Telephone Num ers <br /> CL <br /> Business Telephone No. c Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date d� <br /> Please check Applicable Category (1'-7)and Fill in the Requ red Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites N <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 Dation Test Date/Time <br /> 4, LE SANITATION PERMIT <br /> Job Addres /Location—Y15/ <br /> Owner Address �� <br /> 11 SEPTIC TANK El CESSPOOL ❑ LEACHING FIELD 11 �IT AP �CKAGE P ANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW �f(E�A'!R ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 d] <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 <br /> 7. ❑ LAUNDRY For July I,'-June 30, 19 V <br /> fr SIZE; ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. n <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> _ -ml <br /> t <br /> 1 3 <br /> 1 hereby certify that I have prepared this'applfcation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r nd regulations gMV-5)San Joaquin Local Health District.„ <br /> APPLICANT'S SIGNATURE X <br /> I <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July I &Received By July 31. <br /> BILLING REMITTANCE REMIT ` <br /> i BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMO <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - - <br /> OTHER N. r <br /> OTHER <br /> 16� <br /> Received by Date _ Receipt No. Permit No psuancq bate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> . dam . <br /> A <br />