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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 /> I. LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) Address <br /> cOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a.4 Business Telephone Na GO Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) F�-d Title Date — <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 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 & Measures No. MOW <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 /> F R.S. or R,C.E. Name R.S. or R.C.E. No. <br /> I Test Location Test Date/Time <br /> E 4. K SANITATION PERMIT <br /> Job Address/Location L_ v <br /> Owner Address <br /> SEPTIC TANK ❑ CESSPOOL XLEACHING FIELD PrSEEPAGEPIT ❑ PACKAGE PLANT � <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER { <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 F <br /> 4 <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 <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 /> =d <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County { <br /> ordinances, state laws, and rules and regulations of n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 4 <br /> � t <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is;Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31: .. _'❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE r <br /> �e J <br /> LESS i <br /> PRORATION 7 <br /> PLUS <br /> I <br /> PENALTY S I <br /> - 1 <br /> OTHER ' <br /> OTHER <br /> Received by 'Date - - Receipt No. Permit No. Issuance Date Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.13oK.2009 STOC ON,CA 241 <br />