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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - s <br /> i = APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> r Applicat' is hereby mad to c ry on usines i the j 'sdictional area of the Sap Joaq Local Health District <br /> I- Busines ame (DBA Address <br /> I- <br /> Owner Address <br /> Firm Partners, Addresses and Telephone mbers <br /> CL <br /> Business Telephone No, Emergency Telephone No. � <br /> Contractor Licence No. 2 (p 1 <br /> �Applicants Name {Print) Title Date <br /> Please check Applicable Ca ry(1-7) and"In Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, ry June 3o, 19 c- Disposal Sites <br /> Description(Make/Yr:;,Color) <br /> Serial No. _ CAL. License No. <br /> - -� •�,.. ti ��� CAL. License Renewal No. - <br /> Capacity ' - a''Gal., Weights & Measures No. <br /> Equipment Parking Address_ <br /> 2.- ❑ PUMPERXARD .., <br /> For July 1, June 30,-19 ~' <br /> No. of Vehicles Stored y <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�,Lo tion Test Date/Time y j <br /> 4. � SANITATION PERMIT <br /> Job Addre /Locatio A) <br /> Ow�r PT4M Address <br /> L'f SEPTIC TANK 1:1 CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY OINEW ❑ 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) <br /> fi. 11 PACKAGE TREATMENT PLANT For July 1, -June <br /> Operator Name i <br /> 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. r. <br /> ❑-DRY CLEANING, Chemicals Used/Amount/Mo. <br /> MotMAaWriMrmllcenaeda9ent'saiana�ro -- <br /> Itr srrelr manneras to become subject to•workrn ompe_.W laws ceof d1 iIthatt." <br /> Donna:s certiWlirniInttrepcMonnanceofthewt"*forwt►iztrthls <br /> ce00Y Persons <br /> hieing or sub c°rrtracting &8rratere eatttF'ea the loltowf if nB: "I cern , perm Is�},16Snad,lsftaiinetemaloyartyPill oh <br /> employ persons subject to workntart's samAensaiiorr laws of California." certify that in the performance of the work fo wh 3hls yermii is issuett,I shall. <br /> y- .. <br /> _: <br /> I hereby certify that I have prepared this application and that-the work will be done in accordance wit` San Joaquin County <br /> ordinances, state laws, and les and re ati ns of the San Joaquin Local Health District. ". <br /> APPLICANT'S SIGNATURE X I <br /> � 'FOR DEPARTMENT USE ONLY <br /> r -_ \ .r I <br /> Fee IS Due: [] ANNUALLY ❑ PER UNIT `❑ PER SITE El EACH El January 1 &Received By January 31 .❑ July 1 &Received By July 31 <br /> BASE `{ . BILLING REMITTANCE ''. REMIT - <br /> EXPLANATION $ <br /> DATE ' AMOUNT DUE CHECKED <br /> DATE REMITTED '. AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS , <br /> PENALTY r <br /> OTHER - - <br /> OTHER: , <br /> 1-7 _ <br /> Received by Date a Recei t No.' P --i nce.Data <br /> s, , I ua " <br /> P Permit No'- _ Mailed Delivered <br /> APPLICANT—RETURN+ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - ',1601-E.HAZELTON AVE.,P.O.Box 2009 - S1OeeCKT9N,CA452/01 �/ <br />