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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 /> Applicatio is here y m e to r on bus- ess i th jurisdictional area of the S oaquin cal Health Distri <br /> ,Busines (CBA) Address S �► <br /> aOwner L — Address. <br /> 0 Firm Partners, Addresses and Telephone Numbers 7 Ve • A_t,, <br /> aBusiness Telephone No._c36 p �s _ Emergency Telephone No. <br /> Contractor Licence No. "7 <br /> L Applicants Name (Print) Title �fit}�� Date -- <br /> Please check Applicable Category (1-7)and Fill in the Required Information ^ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) `z <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License 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 Lo ation Test Date/Time <br /> 4. I SANITATION PERMIT —+ <br /> Job Address/Locan <br /> Owe r Address t3 <br /> B SEPTIC TANK ❑ CESSPOOL ACHING FIELD WSEEPAGE PIT ❑ PACKAGE PLANT <br /> QIPERMANENT ❑ TEMPORARY ❑ NEW 11-REPAIR ❑ OTHER — <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site o� <br /> No. of Units Equipment Storage/Cleaning Location(s) �I <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 j <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 applic W n and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul s and regulatio of e 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 ❑ January1 &Received 6 January 31 '� "�11 <br /> y ry ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED 7 <br /> DATE DATE REMITTED AMOUNT <br /> FEEL)+� <br /> LESSA <br /> PRORATION <br /> PLUS f <br /> PENALTY ` <br /> OTHER <br /> . r <br /> OTHER <br /> Received by _ Date - -- Receipt Nc. Permit No. ts&uance Date Mailed Delivered <br /> -APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 T <br />