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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> APPLICATION I <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGi i <br /> ENVIRONMENTAL°'HEALTH'PERMIT 4 <br /> LIQUID WASTE i <br /> Application is erebv'made car on bus ess in t jurisdictional area of the Sawd quin Local He D istric i, <br /> y Business a (DBR) ��' Add <br /> re <br /> z Owner �!� Address `� lrO' / <br /> I 7�lJ <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a jEmergency Telephone No. <br /> a Business Telephone No. <br /> Contractor Licence No. � <br /> LApplicants Name (Print) C Title d� Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)s <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.orR.-C.E. No. <br /> R.S. or R.C.E. Name ` <br /> Test Date/Ti <br /> Test Location me <br /> , <br /> 4, SANITATION PERMIT .7. <br /> Job Addres /Location +2 / 1 i _ <br /> Owner - Address ` a <br /> Ef SEPTIC ANK ❑ CESSPOOL LEACHING FIELD Q-5-EEPAGE PIT ❑ PACKAGE PLANT <br /> LI-PERMANENT ❑ TEMPORARY �EW ❑ 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 /> I Operator Name Where Certified <br /> Plant Location <br /> I No. Units Served <br /> Plant Capacity , <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑. More Than 1,000 Sq. Ft. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this ap I'cation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul and regul to the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X or <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdE y ly 31 <br /> BASE EXPLANATION - BILLING REMITTANCE $ AMOUNT DUE CH ED <br /> DATE DATE REMITTED NT <br /> ' FEE S <br /> LESS <br /> PRORATION <br /> PLUS r <br /> PENALTY <br /> I OTHER <br /> f OTHER <br /> f <br /> Received by Date - Receipt No. �rmit No. Is uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. AZELTON AVE:,P.O.Bo>t 2009 - STOCKTON,CA 95201 <br />