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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> tlQUIU WASTE <br /> r Application ' a hereby made t carryon business in the juri fictional area of the S Joaq Local Health Distri <br /> y Business Name (DBA) Address <br /> a Owner4 <br /> Address <br /> Firm Partners, Addresses and Telephone Num ers �a <br /> CL <br /> Business Telephone No. -�1 <br /> 2_ � Emergency Telephone No. <br /> Contractor Licence No. .7 <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:, 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 /> i <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 Lgzation Test Date/Time <br /> i <br /> 4. SANITATION PERMIT `^ <br /> Job Address ocation, <br /> Owner <br /> ❑ SEPTiC TANK ❑ ESSPOOL BLEACHING FIELD reser si <br /> SEEPAGE PIT� PACKAGE PLANT Z <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW PAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning l.ocation(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> e <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc6-withSan Joaquin County <br /> ordinances, state laws, and r les and regulatio of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 'W A <br /> ..h x <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ? <br /> " ❑ January 1 &Received By January 31 July'l &Received By Jul 31 � <br /> BASE EXPLANATION SICCING REMITTANCE. $' <br /> REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AM 'J <br /> LESS I' <br /> PRORATION - t <br /> PLUS <br /> PENALTY <br /> i. <br /> OTHER � I <br /> OTHER <br /> l � a <br /> Received by Date Receipt No. - Permit No. suan pate Mailetl"^�,pelivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HA2ELT.OH AVE.,O eox 2pp9 STOCKTON,CA 95201 <br />