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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 /> Applicatioln`iIh reb m to carry onbusiness in the jurisdictional area of the San Joaquin Local Health District -7- <br /> H Business Name (f)SA} ", U� �� Address__. / <br /> z <br /> z Owner , i�/t Address <br /> �L� ,, <br /> a <br /> 1 Firm Partners, Addresses and Telephone Nu bers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> <Applicants Name (Print) d t.r i� �% Title Date e <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. License Renceeal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> - --„- ..� <br /> For July 1, June-30-,49------- <br /> No. <br /> No. of Vehicles Stored <br /> No of Chemical Toilets Stored ~� <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.0.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Lotion e, _ <br /> Ot,,Vr Address '� G <br /> SEPTIC TANK ❑ CESSPOOL 0 EACHING FIELD ❑ SEEPAGE PIT ❑ PAGKA°GF=PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> r 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 /> F Operator Name Where,Cees-ified �l r <br /> I <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 rules and r ul of the San Joaquin Local Health District. <br /> i <br /> APPLICANT'S SIGNATURE X <br /> - r <br /> a <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 /> BASE EXPLANATION KILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED 3 AMOUNT <br /> - FEE <br /> LESS <br /> PRORATION <br /> PLUS \. <br /> PENALTY 1 <br /> OTHER 'lam ti <br /> OTHER w ` <br /> Received by Date Receipt No. Permit No. r Issuance Date' Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> s. <br />