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Applications Will Be'Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r r (For Non-Transferable, Revocable, and Suspendable) <br /> G <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio er by ma o car on busi ss in the jurisdictional area of the SanJoaquin Lo H It is <br /> „r Business N e (DB ) Addres d <br /> i Owner Address <br /> d <br /> Firm Partners, Addresses and Telephon Numbee7rs <br /> a. Business Telephone No. l � of �. _. Emergency Telephone No. r <br /> Contractor Licence No. _� �. q�� <br /> Applicants Name (Print) "� Title Date l� yu <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 J Disposal Sites <br /> Description(Make/Yr., Color) ii <br /> Serial No. CAL. License No. CAL" Liccnse Renewal No. t <br /> Capacity Gal.,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. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 4 <br /> R.S. or R.C.E. Name t R.S. or R.C:E. No. <br /> Test cation f Test Date/Time <br /> 4. SANITATION PERMITt <br /> Job Address/ tion <br /> Owner Address -co " <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD Ij SEEPAGE PIT ❑ PAC AGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEWREPAIR ❑ OTHER <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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 f= <br /> Operator Name Where Certified <br /> Plant Location I .. <br /> 11 I <br /> Plant Capacity No. Units Served S v <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft:, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a r e'' regulation oft an Joa n Locat Health District. <br /> R <br /> APPLICANT'S SIGNATURE X <br /> a FOR DEPARTMENT USE ONLY <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH, ❑ January'1 &Received By January 31 0 July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION � � - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS , r <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER y ' <br /> OTHER - <br /> �� �o <br /> Received by Date Receipt No, Permit No. Issuance Dat Mailed Detivered <br /> APPLICANT—RETURN ALL COPIES TO: .ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON .O.Box 2009 STOCKTON,CA 95201__ r <br />