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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 1� (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGI= <br /> LIQUID WASTE <br /> Application is hereby made to caron busine n the j ris ictional area of th San oaquin L cal Health District <br /> N Business Name (DBA) Address� 0 � i� ��a <br /> $ <br /> i Owner �� Address <br /> a <br /> J Firm Partners, Addresses and Tele hone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> _L Applicants Name (Print) Title Date <br /> I Please check Applicable Category (1-7)and Fill in the Required Information <br /> f 1. ❑ PUMPER-VEHI&E PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> f For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Uc:nse Renewal No. <br /> Capacity. GaI:,,Weights &-Measures'No:'° <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> ,. For July 1, June 30, 19 <br /> No. of Vehicles Stored. ------ <br /> No. <br /> �_ _ -__No.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> or R.C.E. Name. R:S__or R.G.E. No. <br /> Test Location t Test Date/Time + <br /> k 4. ❑ SANITATION PERMIT <br /> a Q C_ <br /> Joi Address Location <br /> Ownertr� — Address <br /> ❑ 'SEPTIC TANK ❑ CESSPOOLEACHING FIELD © SEEPAGE"PIT' Y❑ PACKAGE PLANT <br /> ❑-PERMANENT ❑ TEMPORARY f LJNEW REPAIR ❑ OTHER C <br /> 5-11 CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type'-Construction Disposal Site i <br /> Nos of Units Equipment Storage/Cleaning Location(s) - -� <br /> 6. ;❑ ,PACIii TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name` Where Certified <br /> Pla, Location <br /> Plant Capacity � � No. Units Served <br /> 7.r❑ LAUNDRY For July 1, -/June:30, 19 <br /> I SIZE: ❑ Less Than 1,00i Ft" ❑ More Than 1,000 Sq. Ft. <br /> _13.DRY CLEANING, Chemical s=Used/Amount/Mo. t <br /> I hereby^certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state-laws, nd rules and�% ulati s f t San J quin Local Health District. <br /> r APPLICANT'S SIGNATU JA IL, <br /> i T <br /> I ' <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> e Fee Is Due: El ANNUALLY El PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By_July 31 <br /> Y <br /> REMIT <br /> BILLING REMITTANCE $, <br /> � - BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE ,, REMITTED AMOUNT - <br /> � r i <br /> r FEE , <br /> } <br /> LESS <br /> i PRORATION <br /> PLUS <br /> „ PENALTY <br /> y <br /> OTHER i f <br /> F <br /> 4 OTHER <br /> t , <br /> 42-3 <br /> f� <br /> *PICANT.— <br /> Date Receipt No. { Permit No' ; „- Issuan ate Mailed T�^De - 1 <br /> - ; RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> f <br />