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07 <br /> ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. s <br /> APPLICATION <br /> ' - (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> t LIQUID WASTE <br /> Application is hereby made to car on bu 'ness in t e urisdictional area of th n Joaquin Loc Health District <br /> w Business Name (DBA) F_ <br /> t a Owner Address <br /> Address t <br /> Firm Partners, Addresses `'d'Telephone:Num ers <br /> Business Telephone No. Emergency Telephone No. <br /> 2 Contractor Licence No, j <br /> Applicants Name (Print) Title <br /> Please check Applicable Category � Q� Date <br /> (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 0) <br /> r For July 1, June 30, 19 Disposal Sites } <br /> Description(Make/Yr., Color) I <br /> Serial No. CAL. License No. <br /> Capacity CAL. Liccnse Renewal No. <br /> Gal., Weights &Measures No, <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> r 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 <br /> Test Location <br /> R.S. or R.C.E. No. <br />� Test Date/Time <br /> i <br /> 4- 11 SANITATION PER IT <br /> Job Addr s/Locati �Illlllllt pill <br /> Owner <br /> rens INA[141 <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD �EEPAGE PIT C3 PACKAGE PLANT �� f <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 <br /> Plant Location <br /> Where Certified <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. �Q <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> l <br /> f hereby certify ta t I have prepared this application and that the work will be done in'�accordance with San Joaquin County 1 <br /> ordinances, state laws, d rules and r gulati ns oft a San J quin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> t �r/ <br /> f <br /> FOR DEPARTMENT�...,S ONLY <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT Cl SITE ❑ EACH LJ3January 3 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITrTANCE REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE `� <br /> J l i f AMOUNT - <br /> � ( � � � <br /> LESS t �v <br /> PRORATION J f <br /> PLUS �. <br /> PENALTY <br /> OTHER <br /> OTHER f <br /> N P <br /> d 3 q <br /> Rec�foe. a.«s 4 ate Receipt No: Permit No. Issuance Data ail _ <br /> AP.P6IGA{�j—R�TUAN ALLC9PIES�D: E%Nli%0%MENTAI HEAITIi PERMITISERVICES 1601 E.AAZELTON AYE.,P.O. <br /> :t ox 2009 . STOCKTON,CA 95201 <br />