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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 /> _1► ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i hereb m e to carryon usi ess in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Na a (D ) f` - AddressZ�7 <br /> !7 ILI <br /> aOwner Address <br /> J Firm Partners, AddesseBeele�phone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) i• Ylrt Y 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. <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 /> .,r <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location ,y �s� ' <br /> Owner l" K Addre <br /> IV <br /> SEPTIC TA ❑ CESSPOOL LEACHING FIELDSEEPAGE PIT 1:1 PACKAGE PLANT <br /> U PERMANENT 1:1 TEMPORARY EW 11 REPAIR ❑ OTHER <br /> 5. El CHEMICALTOILETS For July 1, -Ju a 30, 19 <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 /> I hereby certify that I have prepared this ap lead and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d r n&fe@uIatilpnS#t1le San Joaquin Loc I Health District. <br /> APPLICANT'S SIGNATURE X h t 4- <br /> l� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY (j <br /> OTHER <br /> OTHER <br /> RWogived by Date Receipt No. Permit No. 111suance Date Mailed Delivered''' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTOry'''W1 <br />