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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati is here y made to carry on bu ess in the jurisdictional area of the Joaq ' Local H alth District <br /> N Business a (DBA) Addr ss <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> i <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> a <br /> L Applicants Name (Print) Title 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) 1 <br /> f Serial No. CAL. License No. CAL, License Renewal No. �V <br /> 4 Capacity Gal.,Weights &Measures No. O� <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July i, June 30, 19. <br /> i No. of Vehicles Stored <br /> No. of Chemical Toilets Stored h <br /> 3. 11 PERCOLATION TEST <br /> r r� <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. ul <br /> Test Location Test Date/Time <br /> e 4. 93 SANITATION PERMIT T <br /> Job Addre /Location <br /> Owner I Address <br /> ❑ SEPTIC TANK ❑ CESSP L ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <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 red this Iic tion and that the work will be done in accordance with San Joaquin County <br /> r' ordinances, state laws, a r sand reg i o e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> I _ <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH - ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATIONBILLING <br /> DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION f <br /> I PLUS <br /> I PENALTY <br /> t OTHER <br /> I <br /> i OTHER t 'VSI <br /> Received by Date Receipt No. - Permit No. - Issuance Date Mailed eliv red l <br /> + <br /> APPLICANT—RETURNALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES1601 E.HAZE ONgVE.,P.O.Bok 2009 STO KTON, 95201 - <br /> R-�'?- <br />