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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) SEhTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is b mad to c rry on business in the jurisdictional area of the San Joaquin�ocal H It i trict <br /> r Business Name (DB ) C Address `I-.�f o <br /> ry- Address )'AMS <br /> z Owner <br /> a <br /> u Firm Partners, Addresses and Tel phone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Title Date <br /> aL Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information t"Psw (!Op <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.No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. SANITATION PERMIT <br /> Job Address/ cat' <br /> rn <br /> Owner 1" Addr s <br /> ❑ SEPTIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY -b�INEW 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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �� ? <br /> OR DEPARTMENT USE ONLY <br /> Fee Is Due: ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE\ DATE REMITTED AMOU T <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Boz 2009 TOCKTON,CA 9520 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL <br />