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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 /> I _ ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> k Application is hereby maA to arry o ine i e jurisdictional area of the Sa a uioc.I Health istrict <br /> rn Business (DBA _ —Address <br /> I <br /> z Owner Address / d. it r <br /> 2 Firm Partners, Addressesand Telephone Numbers CA? <br /> f� �A <br /> a. Business Telephone No. .20V 36F 39 Emergency Telephone No. 'Syq � <br /> a 3o s7,z _ <br /> ' Contractor Licence No. <br /> j 5. <br /> LApp[icants Name (Print) iC Title Date <br /> rt Please check Applicable Category (1-7)and Fill In the Required Information <br /> G 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r„ <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CRL. License fienevaal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> s 2. ❑ PUMPER YARD <br /> k 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.S. or R.C.E.No. q <br /> F mss, <br /> Test Location Test Date/Time <br /> 4. ErSANITATION PERMIT <br /> Job Address Location <br /> 0er. A dress <br /> t SEPTIC TANK ❑ CESSPOOL ErLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLA T^ <br /> ®"PERMANENT ❑ TEMPORARY Gi-NEW ❑ REPAIR ®—OTHER s <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 /> f 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 /> —f <br /> d <br /> I hereby certify that I have pr red this ap a 'on nd that the work will be done in accordance wit %aan Joaquin County <br /> ordinances, state laws, and I and regula f e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> f <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> I - Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &R ceiv 1January 31 ❑ July 1 &Received By July 31 - <br /> IF t BILLING REMITTANCEREMIT <br /> BASE EXPLANATION DATE DATE ITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> sLs <br /> LESS <br /> PRORATION 3 <br /> I PLUS <br /> PENALTY <br /> OTHER 1r <br /> TT <br /> OTHER - $ j V <br /> isRecYHPERMIT/SEIRVICES <br /> eived by - Date 'Receipt Noit.No. Issuance -ate. Mailed Delivered <br /> APPLICANT—RETURN AL'L COPIES TO:. ENVIRONMENTAE - 1601 E.HAZELTON AVE.,P.O.Box 2009 -STOCKTON,-CA 95201- <br />