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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. . <br /> APPLICATION ` ` `.4 <br /> (For Non-Transferable, Revocable, and S_uspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application ' hereby made o caao usiness in the' risdictional area of th San Joaquin Local Health 'strict <br /> rn Business Name BA) 71` Address - <br /> �Lf <br /> a Owner u-2� � Address - <br /> Firm Partners, Addresses and Telephone Numb s a <br /> aBusiness Telephone No. f-$` 5 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title 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., Calor) <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 /> f <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 " k <br /> 4. ❑ SANITATION PERMIT <br /> Job Addr s/Location `""'t <br /> er � � h Address <br /> !�E <br /> OwPPEPTIC TANK PL <br /> 11CESSPOOL LEACHING FIELD ❑ T 11 PACKAGE PLANT 61- <br /> L'J PERMANENT ❑ TEMPORARY ❑ NEW M'REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 l/F <br /> I <br /> Type Construction Disposal Site } <br /> No. of Units' Equipment Storage/Cleaning Location(s) T <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 C` <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. # <br /> S <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 <br /> I <br /> I hereby certify that,l have prepared this application and that the work will be done in accordance with San Joaquin Count <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.( <br /> APPLICANT'S SIGNATURE X ' <br /> FOR DEPARTMENT USE ONLY l� <br /> Fee Is Due:'❑ ANNUALLY ❑ PER UNIT ❑ PER S1TE ❑ EACH ❑ January 1 &Receive y J nu43,31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE sEXPLANATION DATE DATE R I ED AMOUNT'DUE CHECKED -, <br /> I� AMOUNT <br /> FEE 'Ls 130 <br /> LESS <br /> PRORATION <br /> PLUS r <br /> PENALTY 1 <br /> OTHER <br /> JL COTHER - Q <br /> (O S -� <br /> Received by - Date - Receipt No. Permit No. - Iss ance Datte Mailed Delivered ` <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTHPERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 211109 STOCKTON,CA 9520 ! <br />