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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 SEPTAGI= <br /> M <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) Address ' <br />,a Owner Address <br />' Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> � <br /> Applicants Name(Print) Title Date f <br /> Please check Applicable Category (1-7) and Fill in the Required Information Tx I <br /> 1r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites `` <br /> Description(Make/ter., 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 -No. of Vehicles Stored Z <br /> No. of Chem ical.Tgilets-Stored W <br /> 3. ❑ PERCOLATION-.TEST' <br /> R.S. or R.C.E. Names R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT P <br /> Job Address/Location .s+ ' <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKA'GE PLANT' - <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. [ 'CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type'Construction Disposal Site <br /> • <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 Th <br /> Plant Location _ <br /> Plant Capacity No. Units Served _ rl. <br /> 7. Cl-LAUNDRY For July 1, -June 30, 19- <br /> SIZE: <br /> 0, 19SIZE: ❑ 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 rules and regulations of the San Joaquin local Health District. <br /> APPLICANT'S SJGNATURE X <br /> RIO <br /> y r o <br /> ., FOR DEPARTMENT USE ONLY <br /> ` Fee Is-Due: ❑ ANNUALLY ❑ PER UNIT i A '❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> t BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> 1 DATE DATE REMITTED AMOUNT <br /> F— Lli FEE � .,,q <br /> LESS <br /> i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ru <br /> Received by Date Receipt No.- ermlt Nti ,'" ncey to Mailed. -Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVt.,P.O.Box 2009 STOCKTON,CA 95201 <br />