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s Applications Will Be Processed When Submitted Property 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 i ereby�made�car on b siness in he ju ' dictional area of the San Joaquin Local Health Distri <br /> Business Name (DB Address -� <br /> a Owner <br />` Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. La rr-'/D Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill 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. License Renewal No. <br /> Capacity 'Gal., Weights &.Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1,_ June 30,'19 — <br /> t _ t <br /> No. of Vehicles Stored <br /> No. of Chemical_Toilets Stored"" ) --------- ` I <br /> 3. ElPERCOLATION TEST f <br /> R.S. or R.C.E. Name _ R.S. or R.C.E. No. <br /> Test Dation r) Test Date/Time <br /> 4, L'J SANITATION PERMIT <br /> Job Address/ ocation <br /> ! Ow er Address d r <br /> SEPTIC TANK El CESSPOOL LE. HING FIELD ❑ SEEPAGE PIT C1 PACKAGE PLANT <br /> J <br /> PVERMANENT ❑ TEMPORARY WHS�EW ❑ REPAIR ❑ OTHER <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) <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. O'LAUNDRY-'For'July1, -June 30, 19 <br /> SIZE: ❑ Less Than 1 000+Sq. Ft., ❑ More Than 1,000 Sq. Ft. s <br /> ❑ DRY GLEANING, Chemicals Used/Amount/Mo. <br /> k <br /> I hereby certify that I have prepared this application and that the work will be-done in-accordance t an Joaquin County <br /> ordinances, state laws, and ru d regulations of the an Joaquin Local Health District. <br /> I � <br /> APPLICANT'S SIGNATURE X ' _- .. '" +' ` <br /> �- FOR DEPARTMENT_ USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH - ❑ January 1 &gecei da <br /> DATE ary 31 ❑ July 1 &Received By July 31 <br /> I REMIT <br /> �- BASE EXPLANATION <br /> BILLING REMITTANCE DATE E ITTEU AMOUNT DUE CHECKED _ <br /> AMOUNT <br /> 'f qFEE <4 41A <br /> f LESS t <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER - f <br /> OTHER <br /> ±. Received by Date Receipt No. Permit No. Issu�ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:: .I ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />