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`Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br />'� HX (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i ereby made tcicarry on b iness'n the jur' diclional area of the SgaJoaquin Local Health Di ict <br /> Business Na (DBA) ` `''�- Address <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Num ers <br /> aBusiness Telephone No. Emergency Telephone No. -�— <br /> Contractor Licence No. Z Z Z <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7) and FIll in the Required IrAllormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, .June 30, 19 Disposal Sites <br /> I Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Llcc ise Renewal No. <br /> E <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. fG SANITATION PERMIT f <br /> Job Address/ ati n etc 1 t�tJ z-u� ` <br /> O^wrio r eAddress 6 <br /> LET PTIC TANK CESSPOOL LE CHING FIELD �� _ IT ❑ CKAGE PLANT <br /> lig PERMANENT ❑ TEMPORARY ❑ NEW WIREPAIR ❑ OTHER CJ' <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19. <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) ;rl <br /> 6. ❑ PACKAGE TREATMENT PLANT For,July 1, -June 30, 19 --4�. <br /> Operator Name _ Where Certified <br /> Plant Location t <br /> Plant Capacity t No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 1,9 <br /> I <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 he done in accordance with San Joaquin County <br /> ordinances, state laws, and r es and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X n <br /> - I <br /> I <br /> t <br /> I <br /> 3 FOR DEPARTMENT USE ONLY 1, <br /> k '1 <br /> Fee Is Due: ElUN <br /> ANNUALLY ❑ PER IT ❑ PER SITE ❑ EACH ❑-JI nuary i &Received By January 31 ., y 1 &Received By July 34 <br /> r BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DAT REMIT MOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS I <br /> PENALTY <br /> OTHER 1 <br /> OTHER <br /> Received by Date Receipt No. Permit No Issu nce ate Mailed eli red <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Bo■2CG9 STOCKTON,CA 95201 <br /> ». - = - <br />