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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ., ENVIRONMENTAL HEALTH PERMIT SEPTAGE = <br /> LIQUID WASTE <br /> Applicatiorpis he eby e carry bu in 55 in the jurisdictional area of the Joa " Local Health D' nct <br /> ,r Business a (DBA) y�,. Addres 4 <br /> a Owner/L !.r�._.�, /s f'a Address <br /> I' <br /> Firm Partners, Addresses andTelephoneNumbers <br /> 542-F, <br /> a Business Telephone No. 9'f_3u Emergency Telephone No. <br /> $ Contractor Licence No. <br /> Applicants Name (Printf-e- Title -fW �'— 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. Licznse 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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT � j <br /> ` Jab Addre Location &J �x- <br /> Owner oAddress 's <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT —S <br /> ❑ .PERMANENT ❑ TEMPORARY ❑ NEW (,REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For Juiy 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> i 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 /> I• 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 /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo.. <br /> I; I hereby certify that 1".have prepared this applic tion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulatio 0 he n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE - EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �• AMOUNT <br /> t' <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ., - Received by Date Receipt No. Permit No Issuance Date Mailed Delivered I _ <br /> -. R <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 sTOCKTON,CA 95201 <br />