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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. s <br /> APPLICATION <br /> Y ""y (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio by mad arryt usiness the jurisdictional area of the San Joa uin L I Hea Di is R <br /> m Business N e DBA) �t� <br /> Addres f1 <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Nu hers <br /> a Business Telephone No. `a l <br /> a Emergency Tel hone No. <br /> Contractor Licence No. 0 <br /> tj <br /> Applicants Name (Print) Title ` Date " <br /> Please check Applicable Category (1-7) and Fill in the equired Information ; <br /> f 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> J 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 S Measures No. 1 <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 <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test L cation Test Date/Time <br /> 4. SANITATION PERMIT P {h <br /> Job Address/ C tion <br /> t Owner Address <br /> SEPTIC TANK TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT Q <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> C Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified Q <br /> Plant Location ¢ <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r <br /> I hereby certify.tP&n_h_a_V_e'0Vpared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, stat laws, Viand regulations o e San J uin Local Health District. <br /> APPLICANT'S SIGNATURE n <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT .❑ PER SITE ❑ EACH ❑ January 1 &Re y January 31 © July 1 &Received By July 31 <br /> BILLING REMITTA E REMIT <br /> BASE EXPLANATION $ CHECKED <br /> DATE DATE EMITTED AMOUNT DUE AMOUNT <br /> FEE C /� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> F <br /> OTHER I <br /> Received by Date Receipt No Permit No, Issuance Date Mailed Deliver <br /> 201 <br /> A <br /> ���-- APPLICANT—RETURN ALL COPIES TO:'` ENVIRONMENTALHEALTHPERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOC ON,C9 <br />