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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> •s . _" APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE , <br /> LIQUID WASTE <br /> Applicati is ereby m to carry on siness in the jurisdictional area of the San Joaquin cal al ict <br /> Business mBe { ) Addr s <br /> z17 <br /> a Owner Address <br /> J Firm Partners, Addresses and Telephone Numb <br /> o. Business Telephone No. IVS"c �/Z� Emergency Telephone No. y <br /> Contractor Licence No. �P 3 <br /> 4 Applicants Name Print <br /> L (Print), Title Date <br /> Please check Applicable Category (1-7)and Fill in the 4equired 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 i <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 /> 4. JZ SANITATION PERM ` cy <br /> Job Ad ss/ o atio /� % -,7 <br /> Owner �, f .C ... <br /> Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> V'PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER J <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 Where Certified � { <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 . i. <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 and reguiatio s of the SP Joaquin Local Health District. <br /> f f <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 17 ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 4 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED MOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> e <br /> LESS ' <br /> PRORATION <br /> PLUS ' <br /> y <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Deliver <br /> -APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1501 E.HAZELTON AVE.,P.O.Box 2008 STOC ON,CA 4 1 <br /> �. <br />