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Applications Will Be Processed When Submitted Properly Completed. Be Sure'To Sign The Application. Y, `.- <br /> APPLICATION <br /> s (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> + Appli,atio ereby mad to arry on busines in t e}uri ictional area of the Sa Joaqui Local Health Distr' <br /> NBusiness Name A f Ad ress 6 0 <br /> aOwner Address C <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No.—r �g-Jjz9 „ Emergency Telephone No. g <br /> Contractor Licence No, <br /> Applicants Name (Print) Title Date `��� �_ <br /> Please check Applicable Category (1-7)and Fill in the Required In4nation <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. " <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD - <br /> s <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST I <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test."ecation t Test Date/Time <br /> 4. 0 SANITATION PERMIT <br /> Job Address/Location "r <br /> Owner � Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT`* ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 0'REPAIR ❑ OTHER a <br /> S. ❑ 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 I <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 accordance with San Joaquin County <br /> ordinances, state laws, and r rid regulations of t Joaquin Local Health District. d <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By JanuaN 31 ❑ July 1 &Received By July 31 <br /> RE IT <br /> BASE - -EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CH EO <br /> DATE DATE REMITTED AM <br /> N4t T4 <br /> FEE s� sq <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY / <br /> OTHER <br /> OTHER - <br /> `Y .. <br /> Received by Date Receipt No Permit No. I IssuaAce Date Mailed ivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA.95201 -' <br />