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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> . <br /> (Fof Non-Transferable, Revocable, and Suspendable) SEPTAG>_ , <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl icatiorl Is hereby de t carry prrtlus' a in the jurisdictional area of the S oaqLoca!H alth Di rict _12, ' <br /> o/ du <br /> Business Na (DBA) Addr ss <br /> zOwner ress I I 1 <br /> 4 �y <br /> Firm Partners, Addresses and Tele hone Numbers <br /> a. Business Telephone No. X33 Emergency Telephone No.� <br /> Contractor Licence No. E 77 <br /> L Applicants Name(Print) L Title <br /> Please check Applicable Category (1-7)and Fill in the Required information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) a <br /> For July 1, June 30, 19 Disposal Sites <br /> I <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal Nol. <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. _ <br /> Test Location Test Date/Time <br /> 4. IT ,ANITATION PER IT J <br /> Job Addres ocation <br /> Owner LAI <br /> Addresses <br /> E SEPTIC TANK ❑ CESSPOOL LEACHING FIELD CirSEEPAGE PIT ❑ PACKAGE PLANT �l <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ' F�'REPAIR ❑ OTHER t <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site OQ <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 <br /> Plant Capacity No. Units Served 5 <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 /> t <br /> I <br /> I hereby certify.that I have prepared tplication d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules an r lations oft n aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE LY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT la PER SITE ❑ EACH ❑ J t ceived By January 31 ❑ July 1 &Received By July 31 y <br /> BILLING RE T <br /> REMIT <br /> AMOUNTDUE <br /> BASE EXPLANATION REMITTED CHECKED <br /> DATE 4 AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> l OTHER - <br /> I <br /> _ Received by - Date Receipt NO. Permit No. Issuance Date Mailed Deliver dr <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON P.O. 8� O O -C 9 01 <br /> // ( , rr <br />