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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 /> LIQUID WASTE <br /> Applicq1tAn is hereby m e to c rry on b sines i he j isdictional area of the S n Joaq Local Health Distr'ct <br /> NBusines ame (DBA Address <br /> aOwner" Address <br /> Firm Partners, Addresses and Telephone mbers <br /> = a Business Telephone No. � � -S7�� Emergency Telephone No. <br /> Contractor Licence No. '2�e� <br /> LApplicants Name-(Print) Title Date <br /> Please check,Applicable C egory (1-7)ane Required Iniormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July.1-, "June 30, 1R Disposal Sites <br /> Descript'ion'(M6ke/Yr.,'Color) .4 <br /> Serial No. CAL. License No. CAL. Liccnse Rencwal No. r <br /> ` -r_ :A:" <br /> Capacity Gal., Weights & Measures No. , <br /> r 4 <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. orfl.C.E. Name ° R.S. or R.C.E. No. + <br /> Test�Loc�tion Test Date/Time -' �" _ <br /> 4. t?SANITATION PERMIT <br /> Job-_Address/Location - <br /> Ow.raer: L• ' Address .� 3- - <br /> 0 S�PTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT PACKAGES PLANT y,,,,��1 <br /> k IMPERMANENT ❑ TEMPORARY ❑ NEW G�3EPAIR �� 1�/ j* <br /> 1. 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19' w :� <br /> Type Construction Disposal Site <br /> No Of Units Equipment Storage/Cleaning Location(s) <br /> i 6.-0 PACKAGE TREATMENT PLANT ''For July 1, -June 30, 19 <br /> �% <br /> Operator Name LAW Where Certified <br /> Plant Location r '� <br /> Plant Capacity No.--Units Served <br /> r p y - <br /> 7.'❑ LAUNDRY For July 1, -June 30, 1.9. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft'; El-,More Than-1,000 Sq.-Ft. <br /> ❑,DRY CLEANING, Chemicals Used/Amon t/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, d rules a regu tions of the San Joaquin Local Health District. r <br /> APPLICANT'S SIGNATURE X <br /> I y <br /> , <br /> _ 1 <br /> FOR DEPARTMENT USE ONLY <br /> I ` <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑January 1.&Received By January 31 ❑ July I &Received By July 31 <br /> I <br /> REMIT <br /> BILLING REMITTANCE $ <br /> I BASE - EXPLANATION - RMOUNT DUE CHECKED <br /> DATE <br /> .. _..-..,M....�. .t•,•--,�...�...� ._ DATE— DATE� DATE �REMITTED-....� .-�-e+��, �,... � - AMOUNT <br /> FEE <br /> LESS <br /> PRORATION' - <br /> PLUS S/ <br /> PENALTY I <br /> i OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No- Iss ante Date Mailed Delivered , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br /> r <br />