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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 /> LIQUID WASTE <br /> Applicatio •Zheby mad carry sine •n the jurisdictional area of the San in cal Heal�D­ t <br /> m Business N e {DBA) Addr &1;, { <br /> a Owner Address s <br /> t <br /> o Firm Partners, Addresses and Telephone N,m bers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 3 <br /> Applicants Name (Print) Title Date �s <br /> Please check Applicable Category(1-7) and Fill in the Requiredinfor ation <br /> li 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) +3 <br />€ For July 1, June 30, 19 Disposal Sites <br /> i Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc-ise Renewal No. <br /> Capacity Gal., Weights& Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> k For July 1, June 30, 19 <br /> I No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> t: R.S. or R.C.E. Name R.S. or R.O.E. No. } <br /> Test Location Test Date/Time ` <br /> l 4. t4 SANITATION PERMIT 8, ZS <br /> i Job Addr—JI ocat, 7 <br /> Owner`I a Address �s <br /> ❑ SEPTIC TANK ❑ CESSPOOL 19 LEACHING FIELD - $'SEEPAGE PIT ❑ PACKAGE PLANT <br /> 3 PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br />} 5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br /> r 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 /> r SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 1 ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i 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, a ru sand regulations f*the San oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I ' <br /> FOR DEPARTMENT USE ONLY <br /> F <br /> Feels 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 ,AMOUNT'DUE -CHEGKED - <br /> DATE DATE REMITTED AMOUNT <br /> I FEE a <br /> ` LESS <br /> PRORATION ►^ __ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> L <br /> ' OTHER <br /> ? Date Receipt No .Permit No, issu nce ate Mailed Deliver <br /> Received by <br /> i <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE:,P.O.Boz 2009. STOCK ON,Y111 <br />