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Applications Will 8e-Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> -'� APPLICATION <br /> } <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) Address <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. e <br /> Contractor Licence No. { <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category pp g ry (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. Liccnze Renewal 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. <br /> tored 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Tet Location I Test Date/Time <br /> 4. SANITATION PERMIT 1.16c, <br /> Job Address/Location `{ <br /> Owner <br /> y� - U ) Address <br /> }al SEPTICTANK El CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ElPACKAGE PLANT p�1 I <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 /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name - Where Certified # <br /> Plant Location <br /> tt <br /> Plant Capacity f No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 191 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. . <br /> } <br /> I hereby certify that I have rep d,t is applica ' n and that the work will be done in accordance with San J aquin County < <br /> ordinances, state laws, and es ands ulations a San Joaquin Local Health District. jj 1 <br /> APPLICANT'S SIGNATURE X L�U�I!� <br /> .4 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> �'I _:��� - ..�• _�-W�.-_- - REMIT - <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION r <br /> PLUS <br /> PENALTYH91 �+ <br /> • `t <br /> OTHER <br /> OTHER <br /> 4N a %A, <br /> Received by Date Receipt No. Permit No. Issu nce to Mailed Delivered j <br /> APPLICANT'—RETURN ALL COPIES TO:, ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELT .,P.O.Bax 2009 STOCKTON,CA 95201 <br /> i <br />