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act <br /> 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 /> k <br /> Applicatio reby a te <br /> I- rry o business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) Address <br /> Owner <br /> I c Address '-e <br /> 1 Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> a _ .. <br /> L Applicants Name (Print) { Titles Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information ,. >1 <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 Renewal No. , <br /> Capacity Gal., Weights &Measures No. a <br /> Equipment Parking Address 4 <br /> 2. ❑ PUMPER YARD ! <br /> For July 1, June 30, 19 <br /> No, of Vehicles Stared ` <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 Location (1 Test Date/Time' '� r <br /> 4. D(SANITATION PERMIT 'V/ `d tet. <br /> Job Address Location 1J✓a a } — n "j-5r K C ti <br /> Owner Address U L`" v <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 5LNEW ❑ REPAIR ❑ OTHER <br /> 5.."❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction _ --,_ Disposal Site-- f <br /> No. of Units Equipment Storage/Cleaning Location(s) - "u (► <br /> 6_,E] PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ; <br /> Operator Name = Where Certified <br /> Plant Location. 1 <br /> Plant Capacity i! No. Units Served + <br /> T ❑,LLAUN_DRY For July 1, -June 30, 191( <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. I <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Ir <br /> rp <br /> I hereby certify that I have prepared this application and that the work will be one In accordance with San Joaquin County <br /> ordinances, state laws, and r nd re k 'ons <br /> off the San aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Y� <br /> } <br /> FOR DEPARTMENT USE ONLY,, <br /> Fee Is Due:,O ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 _ <br /> REMIT <br /> []ATE DATE REMITTED AMOUNT DUE CHECKED _ <br /> AMOUNT <br /> FEE S <br /> LESS r _ <br /> PRORATION r , <br /> PLUSf <br /> PENALTYY�VAA,'A <br /> q <br /> i <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No- Permit No. Issuance Date Mailed Delivered IR <br /> APPLICYANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.-HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95261 <br />