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{ ApplicationsWill BeProcessedWhen 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 /> Appfication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name fOBA) Address _ <br /> aOwner 1- Address <br /> r <br /> J Firm Partners, Addresses and Telephone Numbers <br /> Q. <br /> Business Telephone No. `f 1 Emergency Telephone No. <br /> Contractor Licence No. 0 W 6_,4a_ <br /> L Applicants Name (Print) — t-l«- (_ 230Lt , Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required information F <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,.Color) <br /> Serial No. CAL. License No. CAL. Licc,ise Renewal filo. <br /> Capacity Gal., Weights & Measures No. <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. or R.C.E. Name R.S. or R.C.E. No. i <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 1-1NEW 11REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> r � / <br /> Type Construction Disposal Site r b <br /> No. of Units '-z 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. 4 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. f <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 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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> p <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> r <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered - - ? <br /> ,ANT—,RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA%201 r <br />