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ApplicationsWill 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 /> r ADB } is here y ma a to c on bu inesspn t <br /> ry, jur' dictional area of th Ji�c, ealth Dis t <br /> F Busin ame {DB Address, � E,� <br /> zz Own r Address <br /> 1 Firm Partners, Addresses and Telephon umbers <br /> CL <br /> Business Telephone No, Emergency Telephone No. h <br /> j Contractor Licence No. OC1 <br /> L Applicants Name (Print) 00_ Title Date 1� - <br /> Please check Applicable C gory (1-7)and Fill n the Required information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) (77 <br /> For July 1, . June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color)- <br /> Serial No. _ - CAL. License No. CAL. Liccnse Renewal No. <br /> i Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address z <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 /> Testi L tion Test Date/Time <br /> 4. t� SANITATION PER _ ` r <br /> Job Addre /L ation C� <br /> Owner Address <br /> ff,SEPTIC TANK ❑ CESSPOOL 141LEACHING FIELD R SEEPAGE PIT• ❑ PACKAGE PLANT t <br /> PERMANENT ❑ TEMPORARY ❑ NEW O-PEPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 bi <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> &. ❑ 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 /> - r <br /> Rome ownerorlicensed agent's signature certifiestthefollowng:"IreythatInthe perfarmandithe-work forwhichthis permit Isissued,Ishall not em <br /> in such manner as to become subject to wa0mipn's compensali'm€a;vs�r CalllorFtla ' <br /> Contractor's hiring or sub-con2rn_!'rr� n • f hi I <br /> iS3 ai#UWrtta. C,rtit-, 3t in.lie penor ,rand ut the ,roti(i0f iv ch ii" titit" iS :'{ Shall <br /> persons sta7jCt;t to Us t...,. ..,, . <br /> I hereby certify that I have prepared this application and that the work will be done it accordance with San Joaquin County <br /> ordinances, state laws, an rules and regu ions f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - ! <br /> r <br /> , � r <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> BILLING REMITTANCE' $ i REMIT <br /> BASE EXPLANATION DATEDATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT ` <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> i ,Z3 v <br /> Received by Date Receipt No. Permit No. Iss nce Datd Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />