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T Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1 <br /> APPLICATION <br /> . _ i(For Non-Transferable,Revocable, and Suspendable) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ApplIcat is hereby made,to c rry on business in the jurisdictional area of theAddress �)1Sn Joaquin L cal H alth IC <br /> t <br /> y 06 <br /> Business Name (DBA) <br /> z Owner Address <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> �Contractor Licence No. Date <br /> 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 /> For July 1, June 30, 19 Disposal Sites <br /> r: <br /> Description(Make/Yr., Color) <br /> CAL. License No. CAL. License Renewal No. <br /> Serial 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 /> II Test�Loca 'on Test Date/Time <br /> 4. 'SANITATION PERMIT <br /> i 0 <br /> jSEPTIC <br /> Ad ss/Locationer Address❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT Q TA ❑ <br /> r PERMANENT 13TEMPORARY NEW ❑ REPAIR OTHER <br />} 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> L Type Constructs.. Disposal Site <br /> r No. of Units Equipment Storage/Cleaning Location(s) <br /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> I Plant Location <br /> Plant Capacity No. Units Served <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 /> j <br /> pared this application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that i have pre <br /> ordinances, state laws, and rules and regulations f the San Joaquin Local Health District. <br /> I APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> q Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Received By January 31 ❑ July 1 &Received <br /> REMIT <br /> uly 31 <br /> i BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I FEE U✓ <br /> LESS <br /> i PRORATION <br /> PLUS <br /> It PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> Received by I IDate Receipt No. Permit No. Issuance Date ailed Delivered <br /> < - APPLICANT--RETURN ALL COPIES TO: <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AV .Box 2009 'STOCKTON,CA 95201 <br />