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Applications Will Be Processed When Submitted Properly Completea. tseaure rU 01MI. `..Nr�... <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEP <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i her bye to on C n�in the jurisdictional area of the San Joa in Local Health Dis rictvE� <br /> Address <br /> w Business N e (DBA) <br /> Address <br /> I.- <br /> Owner <br /> 1 Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> a Business Telephone No. <br /> a <br /> Contractor Licence No. r Date <br /> Title <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1- ) and Fill in the Required lnformation �1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License 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 /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT Q v <br /> Job Address/Luca ion C/ <br /> Address <br /> Owner ❑ PACKAGE PLA T <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD EPAGE PIT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> s. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules a d regulations of the Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE.X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 0�_PER SITE ❑ EACH - ❑ January 1 &Received By Sanuary 31 ❑ July 1 &Receiv <br /> REMIT ed By 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE T 1rf �CJ10+/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER — �• <br /> OTHER r� <br /> / 6 3 Issuance Date Mailed Delivered <br /> Received by <br /> Date Receipt No - Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSER 5601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95 <br />