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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. k <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) d <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> t <br /> in LIQUID WASTE <br /> Applica ion is hereb m de to car n si es the' i ictioaal area of t a quin o l H I! Dis rict <br /> F Business Name (DBA Address ' 4 <br /> z Owner Address <br /> Firm Partners, Addresses a T hone Number a <br /> aBusiness Telephone No 7 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print} ' Title Date n <br /> Please check Applicable,Category (1-7) and Fill in the Required Information d <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites t5� <br /> Description (Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. L("ase Renewal No. <br /> "Capacity —GaI�;-Welghts-& Measures No:- �- •°-�- -----� -�--�-- - -- ----- <br /> Equipment Parking Address <br /> i ❑ 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. or R.C.E. Name r R.S. or R.C.E. No. <br /> Test Location Test Date/Time e- <br /> 4. ❑ SANITATION PE MIT 4'i + <br /> Job Ad /Location Re <br /> Owner nAddress V4�N 101T= <br /> E]❑ SEPTIC TANK CESSPOOL _ '%LEACHING FIELD SEEPAGE PIT -' ❑ PACKAGE PLANT ' <br /> 11 PERMANENT 13TEMPORARY `l-NEW REPAIR ©_OTHER ry. <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction _ s Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) r "" <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified ' <br /> Plant LocationUl <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. f <br /> © DRY CLEANING,Chdmicals Used/Amount/Mo. ; <br /> �s } <br /> I hereby cert t have preparf this appli tion and that the work viii)I'be done io aceordarice with San Joaquin County <br /> ordinances, state laws dsrtil s an re atio- of k. `San Joaquin Local Health District. T <br /> APPLICANT'S SIGNATURE <br /> - .y� <br /> FOR DEPARTMENT USE ONLY _ <br /> 4 <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE g 0 REMIT <br /> SASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> ULESSdill <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER '. <br /> t <br /> i <br /> OTHER <br /> X1'1 G 5 42D <br /> _ � 4 <br /> Received by - Date Receipt No. - Permit No. I Issuan at Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 } <br />