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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) ~ j <br /> _ ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> y LIQUID WASTE <br /> Application is herebye to carry b s in the jurisdictional area of the Sa- oaqu ocal Health Dist / <br /> Business N (DBA) fddress 41 ° <br /> Owner— <br /> Firm <br /> Ads <br /> Firm Partners,Addresses and Telephone Numbers <br /> umbers / sE <br /> � <br /> iBusiness Telephone No. Emergency Telephone No. JAA" <br /> -J Contractor Licence No. <br /> L Applicants Name {Print' --- <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.Liccrlse Rencwaf No. <br /> Capacity Gal.,Weights & Measures No. v <br /> Equipment Parking Address -- r <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 Location __ -Test Date/Time. — -- -- <br /> 4. SANITATION PERMIT �} , <br /> Job Address/Location <br /> Owner -- Address +2J� l -- <br /> E'S`EPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> (PERMANENT ❑ TEMPORARY 2 NEW ❑ REPAIR 61-OTHER Su' <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 /> I 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 s . <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.. ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 1 <br /> I hereby certify that I have preps is applicatio nd th t the work will be done in accordance with San'Joaquin County <br /> { ordinances,state laws, and rul a regulations of a oaquin Local Health District. <br /> I APPLICANT'S SIGNATURE X <br /> fE FOR DEPARTMENT USE ONLY <br /> k4 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 7- <br /> LESS <br /> ❑ EACH ❑ January 1 8 Received By January 31 [].July 1 &Received By July 31 <br /> i " REMIT <br /> r BASE EXPLANATIOBILLING REMITTANCE b AMOUNT DUE CHECKED <br /> t DATE DATE REMITTED AMOUNT <br /> f FEE <br /> - Lr <br /> PRORATION <br /> PLUS <br /> PENALTY — - - <br /> OTHER <br /> OTHER .I r <br /> Received by Date Receipt No. Permil No Issuarice Date Mailed 1' red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,.CA 95201 <br />