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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> mar Non-Transferable, Revocable, and Suspend,_, <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SEPTAG� <br /> LIQUID WASTE <br /> Application is rebyc made to arty o busi s in the' . tional area of the Sa oa uln_Local Health District a <br /> Business Nam BA) Address � � �'�� <br /> i Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> c Business Telephone No Emergency Telephone No. <br /> Contractor Licence No._ 'a.7— <br /> c Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required r6fIrmation <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 t, June 30, 19 <br /> 1 <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 L tion Test Date/Time <br /> 4. VSANITATION PERMIT G <br /> Job Address/Location t` <br /> Owner Address y _— <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEA HING FIELD E PIT 11PACKAGE PLANT <br /> 11PERMANENT ❑ TEMPORARY C3 NEW C�iEPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> IS ❑ 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 Jily 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 cep y that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances. sate laws, and rules an gulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ --.'-ALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �l <br /> f <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ante Date Mailed eli eyed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br />