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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �. <br /> APPLICATION <br /> r Non-Transferable, Revocable, and Suspendabi <br /> ENVIRONMENTAL HEALTH PERMIT w SEPTAGE <br /> LIQUID WASTE <br /> Applic n is hereyby m e to c rry o. b sines i he j isdictional area of the S n Joaq Local Health Distr t <br /> rn Busines arae {DBA Address- . fit; �f�7 �r <br /> —,� -- <br /> z Owner Address — <br /> a <br /> j Firm Partners, Addresses and Telephone mbers <br /> CL Business Telephone No. Emergency Telephone No. <br /> 07 <br /> Contractor Licence No. Z <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable C egory (1-7)and Fill i e Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I <br /> For July:1, June 30, 19 Disposal Sites_ <br /> Description (Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licczse 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 /> i <br /> No. of Chemical Toilets Stored 1 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test�Loc�tion Test Date/Time <br /> 4. L� ANITATION PERMIT i <br /> Job.Address/Location <br /> Owner. L• Address <br /> ❑ S PTIC TANK 13 CESSPOOL 1:1 LEACHING FIELD D SEEPAGE PIT PACKAGE PLANT <br />` t!f PERMANENT ❑ TEMPORARY © NEW 0-1�EPAIR � �✓ <br /> I 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19'- <br /> Type <br /> 0, 19'Type Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> 6. E] PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Op erator Name <br /> Where Certified <br /> _ <br /> Plant Location <br /> Plant Capacity No:Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 1.9 <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 be done in accordance with San Joaquin County <br /> ordinances, state laws, d rules a regu tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLYr . <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JWy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> _ r <br /> -DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS �I <br /> PENALTY I <br /> OTHER <br /> OTHER <br /> i a <br /> Received by� Date Receipt No. Permit No. Iss ance Date Mailed Delivered <br /> - APPLiCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 �Q - <br /> s •f' <br />