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I Applications Will Be Processed When Submitted Properly Completed. B <br /> APPLICATION e Sure To Sign The Application. <br /> � <br /> 'C" (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT j 5 , SEPTAGE <br /> t LIQUID WASTE <br /> I Application i hereby made t car on b iness in the juris ctional area of the San Joaquin Local Health District <br /> H Business Name (DBA Address <br /> aOwner _ Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> I a Business Telephone No. 0 <br /> I dc Emergency Telephone No. M <br /> Contractor Licence No. <br /> a L Applicants Name (Print) Title _ Dater O <br /> Please check Applicable Category (1-7) and Fill in the Req red Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites C' <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. t <br /> Equipment Parking Address <br /> I <br /> 2. 0 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. Name R.S. or R.C.E. No, <br /> Test Lao-_ation Test Date/Time <br /> 4. ®'SANITATION PERMIT <br /> Job Address/Loc�ti n 3 ' <br /> r Address 2— <br /> Owner i( J <br /> ❑ SEPTIC TANK ❑ CESS::]EPOOL - LEACHING FIELD T ❑ PACKAGE PLANT1 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 9?--P'EPAIR ❑ 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 /> S. ❑ 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 /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo, I <br /> t <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 : d regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X > ` <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1!K Received By Jar4arIn, ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE .EXPLANATION $ AMOUNT D CHECKED <br /> DATE - DATE REMITT <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY Y ' <br /> OTHER <br /> OTHER <br /> -7 1 y' i <br /> Received b Z` - ""- v ' <br /> y Date Receipt Nv. Permit No- IsstranCe Date Mailed Delivered - - _ F <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.1iAZELTON AVE.,P.O.aoi 2009 STOCK70N,CA 95201 } <br /> ' <br />