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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 /> Application is her by made to .arty on bu mess in the'urisdictional area of th an oaquin Local Healt D' trict <br /> Business Name (DBA) l ` Address ��• �� d <br /> aC if <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. d Emergency Telephone No. <br /> Contractor Licence No. �f <br /> L Applicants Name(Print} / Title Date <br /> Please check Applicable Category (1-7)and Flli in the Required Information <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;,se Renewal No.. � <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. <br /> Test Lo�4ion Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location I <br /> Owner ?!>7.,o[ , Address ' 21�C� J <br /> C1SEPTIC TANK 11CESSPOOL 7 2 LEACHING FIELD &SEEPAGE PIT ❑ PACKAG>E PLANT �•� P <br /> P-PERMANENT ❑ TEMPORARY,-' �EW ©REPAIR El OTHER lrJ,�1 <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 v I) <br /> Type Construction Disposal Site <br /> No. of Units v Equipment StoraggiCleaning--Location(s) "" <br /> 6. ❑ PACKAGE TREATMENT PLAN7_For J� u ly 1,-June 30, 19 <br /> Operator Name Where Certified _ <br /> Plant Location f <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 /> } <br /> hereby certify that I ha a prepared this applicafion and tha# he work will be done in accordance with San Joaquin County <br /> ordinances, state laws,. d ules and r ulations a San quin Local Health District. <br /> APPLICANT'S SIGNATURE X IKL <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 B Received By July 31 y <br /> REMIT <br /> RASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Pys <br /> s <br /> LESS Lj <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER y—� <br /> OTHER <br /> Ot <br /> Received by Date •� ( ; 3 Receipt No. Permit No. seance Date` ailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON.AVE.,P.O. 09 STOCKTON,CA 9520 <br />