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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 /> SEPTAG£ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereb a to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) F Address <br /> i Owner Ad�re, <br /> d <br /> u Firm Partners, Ad caresses and Telephone Numbers -4:1a. `��a / Emergency Telephone No. <br /> 0. Business Telephone No. <br /> Contractor Licence No. .r <br /> L Applicants Name (Print) Title�W � - 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 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 i, June 30, 19 <br /> No. of Vehicles Stored <br /> i <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 Bate/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location el-0 <br /> Owner G�� � �'� Ad ess LL ' <br /> 11SEPTIC TANK 13CESSPOOL PCEACHING FIELD 11SEEPAGE PIT ❑ PACKAGE P T <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> I a,. <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 " <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) W <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 F W <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> ti <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 -. ' <br /> SIZE ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1400 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 regulafyons of Ioe San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:'El ANNUALLY' [I-PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 El 1 &'Received By July 31 <br /> a. REMIT <br /> BILLING --REMITTANCE --$ AMOUNT DUE T+CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> . FEE !�`-r - ''�'...`�" ++...i. ''• .. <br /> f ,LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Vlermit No. I uance ate Mailed De Fd <br /> APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 21309 .STOCKTON,CA 95201. `� <br />