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Applications Will Be Processed When Submitted Properly Completed. Be SureTosign InePlppncauvEE. w <br /> APPLICATION . <br /> (For Nan-Translerable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE _ <br /> Appiica on Is hereby a to carr on busin sin th risdictional area of the San Joaquin Lo al He ith District— <br /> mBusiness Name (DBA} E AddressSd <br /> z Owner Address �? <br /> a <br /> J Firm Partners, Addresses aoTpephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. ir <br /> Applicants Name (Print) Title <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) CAL. Lic�nse Rer;ewal Na. <br /> Serial No. CAL. License No." _ ,.., <br /> Capacity -" "" T Gal.; Weights'&-Measures No.- !' <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July.1, "June 30:"19 <br /> No. of Vehicles Stored k <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> -_ R.S. or R.C.E. No. y <br /> ' R.S. or R.C.E. Name _ _ <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PE MIT ? {' <br /> Job Addr ss/Location S S . <br /> PC <br /> O ner — `f Add-ress.- <br /> SEPTIC TANK ❑ CESSPOOL} EACHING FIELD ❑ SEEPAGE PIT <br /> PACKAGE PLANT <br /> k, ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR OTHER 1 <br /> ".5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction - - - - <br /> Equipment Storage/ <br /> Cleaning ECleaning Locations ' <br /> � ^No. of Units q P � ) CJI) <br />�Lf 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r <br /> 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 /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,()00 Sq. Ft. <br /> 1 ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> _ F <br /> I hereby certify that I have prep ed this application and that the work will be done in accordance with San.Joaquin.County 4! , <br /> ordinances, st aw , d rules an regu tions the S Joaquin Local Health District. <br /> f APPLICANT'S SIGN R , <br /> FOR DEPARTMENT USE ONLY <br /> ' UALLY ❑ PER UNIT ❑ PER SITE EI EACH ❑ January 1 &Received By January 31 ❑ July 1 &Rem iiv REMITd By uly 31 <br /> Fee Is Due: ❑ ANN <br /> BILLING REMITTANCE $ AMOUNT DUE 'CHECKED <br /> " BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> r` Al' l <br /> F v FEE 1;4 S pp <br /> LESS <br /> PRORATION <br /> I" PLUS <br /> PENALTY <br /> r OTHER J I <br /> t. <br /> t f OTHER <br /> - y7 ` - <br /> Oa[ Receipt No.4 S Permit o r Issuance Date Mailed Delivered <br /> Received by ..� �. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CAA r —-T <br />