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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transierable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i rebyaTipde to p rry o bu ss in he j risdi nal area of the S�yn,�J®uin cal Health�istrict <br /> OF Business Name (D ) Ad ress <br /> aOwner Address <br /> J Firm Partners, Addresses andj...�e,lepp_ho_ne mbers <br /> IL <br /> Business Telephone No. �5 Z42 __ Emergency Telephone No. <br /> j Contractor Licence No. <br /> �Applicants Name (Print) Title 4addvg Date ff-2Q <br /> Please check Applicable Category(1-7) and Fill in the RequireW Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites C <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse 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 Lgization Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/ ati n 14-.14 r <br /> Owner Address ' <br /> QP6EPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ PACKAGE PLANT r <br /> ®"PERMANENT ❑ TEMPORARY ❑ NEW PAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> G <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 accordkag with San Joaquin County <br /> ordinances, state laws, and rules regulations oft San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X10, <br /> l� <br /> FOR DEPARTMENT USE ONLreceived <br /> Fee Is Due: 1:1 ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EAC [Ellnuary 1 By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITT <br /> BASE EXPLANATION DATE DAT $REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> fo <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />