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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Applicanon. <br /> APPLICATION <br /> 5 (For Non-Transferable,Revocable,and Suspendable) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made car on busi s in the risdictional area of the Joa Local Health D' trict <br /> ,�nusiness NI DB Addre a Owner_ C,� Address <br /> u Firm Partners, Addresses dd Telep.4one Numbers Y� <br /> n Business Telephone No. S 0!�Ff ���".3�-�J _ Emergency Telephone No. 17A—O29- <br /> 4 <br /> Contractor Licence No.__ --- - <br /> Applicants Name (Print) JF - Title'r 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 /> No. of Vehicles StoredNo 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 Location - _--.-_ -.-__-.--- Test Date/Time - ----- <br /> A. ❑ SANITATION PERMIT Al <br /> Job Addre /L� j�'atign <br /> OwnerA#Pft'Address ��0^ <br /> SEPTIC TANK 11SP <br /> CESOOL E'CEACHING FIELD I?',TEEPAGE PIT ❑•PACKAGE PLANT <br /> dPERMANENT ❑ TEMPORARY O-TIEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> /pe Construction 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. ❑ LAUNDRY For July 1, -June 30, 19__- <br /> SIZE: ❑ Less Than 1,000 Sq.Ft., ❑ More Than 1,000 Sq. Ft. <br /> 13DRY CLEANING, Chemicals Used/Amount/Mo. - - --- - --- <br /> fe <br /> I hereby certify that I e pre �rg�ulat-toi <br /> ipplic n at the work will be done in accordance with San Joaquin County <br /> ordinances, state la , and r and of e n Joaquin Local Health District. fl <br /> APPLICANT'S SIGNATUR — -- <br /> IF I <br /> FOR DEPARTMENT USE ONLY xW <br /> Fee is Due: ❑ ANNUALLY ❑PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Reckivea 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE nRE AMOUNT <br /> FEE <br /> C. <br /> LESS <br /> PRORATION ..- <br /> PLUS <br /> PENALTY <br /> OTHER 1 <br /> OTHER <br /> PermiReceive0 Oy <br /> Date Receipt No. -- t« 1 u ncee Date -- Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMM/SERVICES 1601 E_HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />