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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION ' <br /> (For Non-Transferable, Revocable, and Suspendable) I <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appli n is hejeby m de to arty on busine in a juri dictional area of th Jo a Local He t istrlc I <br /> HBusines ame (D Address � <br /> aOwne Address <br /> Firm Partners, Addresses and TelephoneNumbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> eo <br /> 41 <br /> Applicants Name (Printf Title Date <br /> Please check Applicable C gory (1-7)and Fill in Required Information ff <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,'Color)' k <br /> Serial No. CAL. License No. CAL. Liccnse Rercwal No. F <br /> Capacity Gal., Weights & Measures No. + t <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD s <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 /> _. _ <br /> Test Lo ation iTest Date/Time <br /> 4. �t SANITATION PERMIT& ,321(v <br /> ' � 'I <br /> Job Address/Lobation & ,327ell A <br /> Owner Addre 73 774/ + <br /> ,❑ TIC TANK CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT r! PA AGE..PLANT <br /> L� PERMANENT ❑ TEMPORARY ❑ NEW 2-15iEPAIR ❑ OTHER . ftp <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 `I I <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name – — Where Certified t <br /> Plant Location r' . <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. t <br /> ❑ DRY CLEAN IN6,Chemicals Used/Amount/Mo. <br /> y <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, an rules and r ula ions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - '– <br /> FOR DEPARTMENT USE ONLY-- n� <br /> Fe0s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By-January 31 ❑ July# &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION D _ AMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS l <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit Noo. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON, 95 91 <br /> �I L.L. 5-A .r 4 71, <br />