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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. , <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati n Is hereb(made to car n b si ss in the jurisdictional area of the Sa ,J 'n Loca`H ealth istrict /J <br /> rn Business a (DBA) Addre s T 4 <br /> z Owner Address 11 O <br /> J Firm Partners, Addresses and Telephone Numbers L C <br /> CL <br /> Business Telephone No. Emergency Telephone No. /n'C- <br /> Contractor Licence No. D'�7� v <br /> d <br /> Applicants Name (Print) �� Title �A)t'L Date <br /> E <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) `Q <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. ; <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parki6g.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. ESANITATION PERMIT <br /> Job Address/Location -I& fit! tl <br /> Owner x1 ►� �e Address 7 O' <br /> SEPTIC TANK ❑ CESSPOOL BLEACHING FIELD L SEEPAGE PIT ❑ PACKAGE PLANT <br /> D-PERMANENT ❑ TEMPORARY 9—NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 /> Q) <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 C <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 pared is application and that the work will be done in accordant with San Joaquin County �l <br /> ordinances, state laws, les and la ons of the San Joaquin Local Health District. �� 1 <br /> APPLICANT'S SIGNATURE �S <br /> I <br /> FOR DEPARTMENT USE ONL <br /> Fee Is Due: 1:1ANNUALLY ❑ PER UNIT ❑ PER SITE F-1EACHJanu r &Rec ived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMI T $ AMOUNT DUE CHECKED <br /> DATE O T REMITTED AMOUNT <br /> �{ D <br /> I FEE � �'� � •/ � ` - <br />! LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ } <br /> OTHER <br />{ OTHER <br /> 6-95,30 <br /> Received by Date - Receipt No. Permit No. Issuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box.2009 STOCKTON,CA 95201 <br />