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APPLICATION <br /> r. <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is,Vereby.made to:carry on bu 'ness in the'unsdig ional area of the San oaq Local Health D' Ict <br /> Business Name (DBA) , '" .� Address , V �- <br /> aOwner - '' r6 Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 3 ,�5��: Emergency Telephone No. �n <br /> Contractor Licence No. <br /> L Applicants Name (Print) = ' wt. 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. Liccnse Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> r <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 ation Test Date/Time <br /> 4. LFJ SANITATION PERMIT <br /> Job Address./IL ation 0 <br /> Owner ' Addres�5FRI <br /> I] SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD EPAGE PIT ❑ PACKAG PLANT <br /> 11 PERMANENT 11 TEMPORARY ❑ NEW EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 (� <br /> Type Construction Disposal Site t� <br /> No. of Units Equipment Storage/Cleaning Location(s) fes, <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 /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> 4w ordinances, state laws, and rul and regulations Of he 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 /> l� <br /> FEE <br /> LESS <br /> PRORATION 1/, <br /> PLUS <br /> PENALTY C <br /> OTHER i <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issu nce Datl3 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 `STOCKTON,CA 95 01 <br /> defer <br />