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Applications Will Be Processed When Submitted Properly Completed.Be Sure'To Sign The Application. `-`r ' <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applieatio ereby mad to carry0n usines int a}uri fictional area of the Sa oaqui Local Health Distr' <br /> H Mess Name A <br /> Ad ress �$ o <br /> Owner Address r <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ,� f <br /> Contractor Licence N0._ " Emergency Telephone No. 4 <br /> L Applicants Name (Print) <br /> Please check Applicable CategoTitle .. Date <br /> PP g ry(1-T)and FiII in the Required Int anon <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. <br /> CAL.License Renewal No. <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address f <br /> 2. ❑ PUMPER YARD •- <br /> For July 1, June 30, 19 <br /> No.Of Vehicles Stored <br /> No.of Chemical Toilets Stored y <br /> 3. ❑ PERCOLATION TEST I <br /> i <br /> R.S.or R.C.E.Name <br /> Test Lortation R.S.or R.C.E.No, r <br /> ► Test Oate,Tme � <br /> 4. IN SANITATION PERMIT l�1 <br /> Job Address/Location <br /> Owner Address <br /> 1:1SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT`--❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW WREPAIR ❑ OTHER I <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 1 <br /> T- Construction <br /> Disposal Site <br /> r Units Equipment Storage/Cleaning Location(s) <br /> 6. .J PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified v 4 <br /> Plant Location E <br /> Plant Capacity <br /> 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 /> r <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,and nd regulations of t Joaquin Local Health District. <br /> • . d <br /> APPLICANT'S SIGNATURE } <br /> 1--� FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY I] PER UNIT ❑ PER SITE ❑ EACH ❑ January1 8 Received a Janu 31 <br /> y ❑ July t a Recewea By July 31 }}} <br /> BASE %1') <br /> REMITTANCE g R IT ` <br /> DATE REMITTED AMOUNT DUE CH ED .df <br /> FEE r--" G AM J , <br /> LESS / <br /> PRORATION <br /> PLUS PENALTYOTHER ' <br /> rHER <br /> Received uy Date ,� .,• <br /> Rece'pt No. Permit No. Issu oe to Mailetl leered I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTHPERMIT/SERVICES <br /> :j � - 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA.95201 ''1 <br />