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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) k <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appl ication is by made to c on busin in th ju ' dic nal area of the S aquin Local Health District } <br /> F Business IZI Address <br /> aOwner Address _ <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Printf Title Date i <br /> Please check Applicable Category(1-7)and Fill in the Required nformation <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 /> j Equipment Parking Address <br /> t 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 Lation Test Date/Time O <br /> 4. LJ SANITATION PERMIT a (� <br /> Jab Addre ocati n D �� c[ 0 <br /> Ower Address,, i pe � <br /> W SEPTI T NK ❑ CESSPOOL LEACHING FIELD SzPAGE PIT ❑ PACKAG PLANT <br /> ❑ PERMA ENT ❑ TEMPORARY ❑ NEW &REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br /> r Type Construction Disposal Site <br /> I No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> ` Plant Location <br /> I <br /> Plant Capacity No. Units Served <br /> r 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 /> 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 r' and regulations an oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X- <br /> i a <br /> FOR DEPARTMENT USE O �llt <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH Jan a &Received By January 31 ❑ July i &Received By July 31 <br /> BILLING RE TAE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE. CHECKED <br /> DATE A REMITTED <br /> . �}. I AMOUNT <br /> {P wEi <br /> FEE L & <br /> LESS <br /> PRORATION �? <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receip No- Permit No. Issu nc0.1P Mailed Delivered <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> I t <br />