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— Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTneAppllcanvn. <br /> ` �zOct APPLICATION <br /> `y (For Non-Transferable, Revocable,and Suspendable) <br /> SEPTA,GE p <br /> a f ENVIRONMENTAL HEALTH PERMIT Q,1 <br /> LIQUID WASTE <br /> Applicati n is h reb ade to car o bust ss in the jurisdictional area of th�5an aquin Local Health District <br /> Business Name (DBA) Address •�Q� � � /' <br /> ' z Owner Address <br /> 4 <br /> U Firm Partners, Addresses and.Tel1.ephone Numbers _ Emergency Telephone No. <br /> d a Business Telephone No. �� �6P� <br /> a - <br /> Contractor Licence No. M� <br /> DatedC l � � <br /> Title <br /> Applicants Name (Print) <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 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights & Measures No. <br /> j 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 R.S. or R.C.E. No. <br /> R.S. or R.C.E.Name <br /> Test Location Test Date/Time <br /> �4 4. R SkkNITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> 13 SEPTIC TANK El CESSPOOL. 81 LEACHING FIELD S( SEEPAGE PIT ❑ PACKAGE PLANT <br /> OTHER <br /> ❑ PERMANENT ❑ TEMPORARY 1:1NEW REPAIR <br /> ❑ <br /> ( 6. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 C' <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 where Certified <br /> Operator Name <br /> r` Plant Location b <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> F SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I. ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 1 <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 regulations of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X _ <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January &Received By January 31 July 1 &ReceivedREMIT 31 <br /> ' BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> ° FEE ✓ <br /> LESS <br /> F PRORATION <br /> PLUS <br /> gg PENALTY <br /> r OTHER <br /> OTHER <br /> r Io <br /> q Date Receipt No. Permit n. Issuance Date Mailed Delivered <br /> Received by 1501 E.HAZELTON AVE.,P.O.Bax 2409 70CKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TOi ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />