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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> y APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT S�PTAGE <br /> LIQUID WASTE <br /> Application is ereby made o carry on usine s in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. S/Q5 Emergency Telephone No. <br /> a <br /> Contractor Licence No. �Z <br /> L Applicants Name (Print) Title 044.9 Date <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) <br /> Serial No. CAL. License No. CAL. Licc Ise 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. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test L ation Test Date/Time <br /> 4. I[J SANITATION PERMIT ' <br /> Job Address/Lion 2-7 <br /> Owner Address <br /> SEEPAGE PIT SEPTIC TANK ❑ CESSP L ❑ ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW P REPAIR ❑ OTHER qJ <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 <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 rule d regulations of th Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �" <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT 11PER SITE ❑ EACH ❑ January 1 8 Received By January 31 E3July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> $ <br /> BASE EXPLANATION DATE DATE REMITTED . AMOUNT DUE CHECKED <br /> d AMOUNT <br /> FEE <br /> LESS <br /> PRORATION •� <br /> PLUS <br /> PENALTY 07 AJ <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issua ce Datle Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,PO.Bo■ 009 STOCKTON,CA 95201 <br />