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Applications 1,111 Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ' Ms (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application,is hereby a to carry busi a in the jurisdictional area of the S Joa Local Health strict /% <br />,�Business a (DBA) p Ad ress p V G f <br /> ,., <br /> a Owner Address <br /> M Firm Partners;Addresses and Telephone Nui4ersr +� <br /> aBusiness Telephone No. i .. Emergency Telephone No. <br /> Contractor Licence No.." f <br /> LApplicants Name (Print) Title 40A) Date f �f <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. El PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,-June 30, 19 Disposal Sites <br /> 3 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> x <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD �t <br /> For July 1, June 30, 19 a <br /> No. of Vehicles Stored <br /> No, of Chemical Toilets Stored ( 6 <br /> 3. ❑ PERCOLATION TEST ! <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addr ss/Location _ � - �'"` ' �- y v 11-, <br /> Address O <br /> Owner -. <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(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 # i <br /> SIZE: ❑ Less Than 1;000 Sq, Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. B <br /> I hereby certify that I have prepared this applica4n and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an5p,117an egulatio a an Joaquin Local Health District. 1 <br /> a <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY • E1-.PER UNIT ❑ PER SITE C1 EACH ❑ January 1 &Received By January 31 -❑ July 1 &Received By July 31 <br /> BILLING.. REMITTANCE $ REMIT , <br /> EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> B <br /> FEE <br /> LESS xr <br /> PRORATION <br /> PLUS ° <br /> PENALTY <br /> OTHER E. <br /> OTHER <br /> .'Received by Date Receipt No, Permit No. -�` Iss anca[Tatf Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C 95201 +' i <br /> .i <br />