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Applicata.ms 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 /> Application e y e to cry n t <br /> n business ihe X risdictional area of the San Joaquun Lo /alt isth t <br /> mBusiness Name (DBA) AddressG '� -'1y �++-� <br /> z Owner Address <br /> 4 /6 <br /> Firm Partners, Addresses and Telephone Numbers 3 44 17� <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date ' <br /> Please check Applicable Category (1-7)and Fill in the Required Information <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. Llc:.nse Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> .as. <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 /> r <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Addres <br /> SEPTIC TANK ❑ CESS OOL EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ERMANENT ❑ TEMPORARY 0,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 Where Certified <br /> Plant Location <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. <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 ule nd eguI ti of the San Joaquin Local Health District <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �s v <br /> LESS <br /> PRORATION f <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1 <br /> OTHER <br /> ' 7 <br /> Received by Date Receipt No. Permit o. Issuance ate Mailed 11blivered <br /> AP T-TURN pL COPIES TO: ENVIRONMENTAL�HEALTH ERMITJS VICES 1 EH�E;LTAVE,,P.O.Box 2009 STOCKTON,CA 5201 <br />