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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> APPLICATION S� <br /> (For Non-Transferable,Revocable,and Suspendable) I <br /> .�' ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE ? <br /> Application s-hereby made t9, rry on business in be jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) "��+�, �• Address <br /> i <br /> ? Owner i 'I Address in - <br /> - '. /� <br /> Firm Partners, Addresses aria.Telephone Numbers, -� } <br /> CL Business Telephone No. 1� �— ' Emergency Telephone No. <br /> Contractor Licence No. i <br /> L Applicants Name(Print) 1� Title 7 .. Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 1 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description (Make/Yr., Color} <br /> Serial No. I' s CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,I Weights &Measures No. <br /> Equipment Parking Address 1!. <br /> 2. 11 PUMPER YARD �' <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> i 1 <br /> No. of Chemical Toilets Stored <br /> 3.—O—PERCOLATION TEST <br /> R.S. or R.C.E. Name IM R.S. or R.C.E. No. <br /> it <br /> Test Location = Test Date/Time <br /> 4.1 C�!'SANITATION PERMIT <br /> i Job Address/Loi tion 11 W .+ <br /> Owner ` I �' - Address y <br /> ❑ SEPTIC TANK ❑ CESSPOOL ity -❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> C PERMANENT ❑ TEMPORARY iI ❑ NEW <br /> REPAIR OTHER <br /> 5. 11 CHEMICAL TOILETS For July 1�-June 30, 19 <br /> Type Construction Disposal.Site <br /> No. of Units A Equipment Storage/Cleaning Location(s) � + <br /> 5. ❑ PACKAGE TREATMENT PLANT i'For July 1, -June 30, 19 <br /> Operator Name �' "�"`� Where-Certified <br /> I' > Y mow'•--.y -. <br /> Plant Location <br /> i Plant Capacity Q I 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 <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, a rules and regulati nsof uin Local Health District. <br /> I <br /> APPLICANT'S SIGNATURE X —f <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: C1ANNUALLY ❑ PER UNIT PER SITE. EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> 1 B �- REMIT <br /> BASE BILLING REMITTANCE $`EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED - <br /> AMOUNT <br /> FEE' ih h <br /> LESS �� Jl <br /> PRORATION <br /> PLUS <br /> PENALTY .7? <br /> OTHER J <br /> OTHER I� l_J<�JI.7 <br /> OTHER <br /> Received by 1� Date Receipt No. Permit No, Issuance Date Mailed Deliv red <br /> - APPLICANT—RETURN, LL COPIES TO::• ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO KTON,C/9520 <br /> 1 <br /> 6*i <br />