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t 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 C <br /> LIQUID WASTE <br />` Appl icatio is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health D lct <br /> mBusiness N%me Address 7 U -�`� <br /> z Owner �� 1. Address -772 U j — " <br /> ,Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. Z <br /> �Applicants Name (PrintTitle Date <br />( Please check Applicable Category (1-7) and Fill in the Required Information <br /> 4 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 /> Y R.S. or R.C.E. Name .. R.S. or R.C.E. No. <br /> I Test Location Test Date/Time <br />'r 4. ❑ SANITATION PERMIT _ <br /> Job Address/Locati n <br /> Owner Address A) <br /> ❑ SEPTIC TANK ❑ CESSP L LEACHING FIELD 00 S IT _C1-PA6K-AGE-PL-ANT - <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 1A REPAIR ❑ OTHER C <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 /> Operator Name _ - 4 Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br />` 7. ❑ LAUNDRY For July 1, -'June 30, 19 y .. <br /> I SIZE=: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> n - <br /> herebycertify that I have prepared this application and that the work will be done-in accordance with San Joaquin Count <br />: Y P p PP q Y <br /> ordinances, state laws, and rules and regulati <br /> ndregulati is o the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> is FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY El PER UNIT ,R PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> - BASE EXPLANATION - AMOUNT DUE CHECKED - <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> I <br /> PRORATION <br /> PLUS i r <br /> I PENALTY - '' - - <br /> e' <br /> OTHER <br /> 7 OTHER --- <br /> Received by -- Date Receipt No. - ermi N . Issuance Dale Mailed--•- Deliver <br /> - APPLICANT—RETURN.ALL COPIES TO: ..ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1501 E.HAZELTON-AYE.,P.O:Box 2009 STOC ON,CA 95201 <br />