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Applications Will Be Processed When SubAPPLICATIONProperly Completed. Be Sure To Sign The Application. <br /> le) SEPTAG <br /> (For Non-Transferable, Revocable, and Sus <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> LIQUID WASTE P�C C <br /> on business in the jurisdictional area of the San Joaqui Local Healtty�istrict —� <br /> Application is h reby ade t0,Cars>}- Address Co <br /> y Lousiness NameD�) Addres� lig' <br /> i 7Owner �¢ <br /> 4 Emergency Telephone No. <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Date Z <br /> 4 <br /> '-JContractor Licence No. Title <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> June 30, 19 Disposal Sites <br /> For July 1, _ <br /> CAL.License Renewal No. <br /> Description(Make/Yr.,Color) CAL. License No. <br /> Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity <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 TET R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name _ Test Date/Time ,^ <br /> Test Location �y <br /> q. ❑ SANITATION ERMITO ,,,Tl �vIs <br /> Job Address/Location d fid' Address <br /> Owner ❑ LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK C1 CESSPOOL 1:1 REPAIR ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY 11 NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction <br /> Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 /> I hereby certify that I have prep ed is =I. tion and that the work vrill be done in accordance with San JO&QW County <br /> ordinances, state laws,and n r ut� of the San Joaquin ocal Health District <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMEW USE OILY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January-y=waived�y, <br /> BASE EXPLANATI(X�i <br /> BILLING REWTTAiNCQ ed 31 ❑ July 1 &Rece,:--- <br /> Sr, Jf� DATE DA'E -WMIT7p AMOUNT DUE �Y _ <br /> FEE <br /> V r iW Ch -'K'_' <br /> Q t✓ AAAC,.i� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY s <br /> 1 OTHER j <br /> OTHER <br /> � r <br /> Received by � <br /> APPLICANT— Date Receipt N0. <br /> RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMM-ERVICES <br /> t6o1 1°e Date <br /> ed <br /> T ON AVE.P.O.Boxl?009 Deli - <br /> STOCKTON CA 95201 <br />