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ApplicationsWill Be Processed When Submitled Properly Completed. Be Sure To Sign The Application. <br /> " • ^��..r <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio h reby m e to rryon siness in thejurisdictional area of the San Joaquin ocal eat D� r' <br /> t <br /> v;Business Name (DBA) _Address <br /> k, Owner Address 01 <br /> QS ,$ <br />? J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. -� 6/� <br /> Contractor Licence No. <br /> Emergency Telephone No. <br /> a � <br /> L Applicants Name (Print) Title r Date 41— <br /> Please check Applicable Category <br /> (1-7) an rmalion " <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FORE CH VEHICLE) r <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr„ Color) <br /> Serial No. <br /> CAL. License No. CAL. License Renewal No, <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2.:.-11 PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored �t <br /> .No. of Chemical Toilets Stored W <br /> 3. ❑ PERCOLATION TEST O <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT �� //� <br /> Job Addre Location ��.3 W <br /> Owner Address <br /> SEPTI TAN ❑ CESSPOOL LEACHING FIELD ❑ <br /> NEW © SEEPAGE PIT PACKAGE PLANT <br /> t6 PERMANENT ❑ TEMPORARY <br /> REPAIR ❑ 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) t <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 <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 /> I hereby certify that I have prepared this application and that the•work will be done in accordance with San Joaquin Count <br /> ordinances, state law ules and reg cations f the San Joaquin Local Health District. y <br /> 4 <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH - ,1 <br /> ❑ January 1 &Received By January 31 ❑-Jufy 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE g REMIT <br /> DATE DATE - REMITTED AMOUNT DUE CHECKED <br /> FEE / <br /> AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - - <br /> OTHER r <br /> OTHER <br /> Received by Date Receip[No. Permit No. F <br /> APPLICANT— Issuande Date Mailed Deliver d <br /> RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> . 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC TON,- 96201 <br />