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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application hereby made carry on bu iness int a jurisdictional area of the S Joaq n Local Health District <br /> H Business Name (DBA r ' s Address �dp 7 <br /> aOwner Address <br /> : Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. s Emergency Telephone No. <br /> ' Contractor Licence No. ';_- Z <br /> Applicants Name,,(Print) I,&. Title „ Date <br /> Please check Applicablw Category (1-7) and FIII In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ry <br /> For July 1, June 30, 19. Disposal Sites <br /> „ Description(Make/Yr.,Color).a _ l am'! .F � _ f• .- `,` <br /> Serial Nod -+_r, _ ;e CAL. License N_o:, �- CAL. License Renewal No. <br /> Capacity _ � - x' `Gal., Weights & Measures No.A~ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> r <br /> No. of Vehicles Stored ; <br /> No. of Chemical Toilets Stored t <br /> 3. ❑ PERCOLATION TEST t ] r <br /> R.S. or R.C.E. Name { -R.S. or R.C.E. No. <br /> Test Lation Test Date/Time q <br /> 4. I►J SANITATION PERMIT <br />' Job Addres /Locatio <br /> Owner ' Address 4 -^ate _ <br /> ❑ SEPTIC TANK ❑ CESSP L ❑ LEACHING FIELD ,C1E PAGE PIT 1:1 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 1 <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 <br /> Plant Location I <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 /> 4 <br /> —T—1 <br /> rr <br /> hereby certify that I have prepared this applica i- that the work will bed ne in accordance with San Jo County <br /> ordinances, state laws, and rules regulations of'the oaquin Local Health District. <br /> i Ik � <br /> APPLICANT'S SIGNATURE X <br /> i <br /> l <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY •❑ PER UNITI PER SITE ❑ EACH ❑ January 1'&Received anuary 31 El my 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> T f DATE DATE RE ED AMOUNT <br /> FEE 5�' • s'!22- <br /> LESS k <br /> PRORATION r <br /> PLUS + <br /> PENALTY <br /> OTHER f r <br /> OTHER <br /> Received by Date Receipt No Permit No.' Issua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601'E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,GA 95201 <br />