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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> _ (For Non-Transferable, Revocable,and Suspendable) <br /> r. ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio i he eby madeV carry an busine n the jurisdictional area of the San Joe Llin cal H al D ct <br /> OF Business me (D ) Addre S <br /> aOwner Address <br /> J Firm Partners, Addresses and Tele hone Numbers <br /> IL Business Telephone No. s` � Emergency Telephone No. <br /> a !3 <br /> L-J Contractor Licence No. �� ��,��.,p������ <br /> Applicants Name (Print) Title • Date���,2sa�_. <br /> Please check Applicable Category (1-7)and Fill in the R quired Information y <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites r <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Lic,:,-Ise 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 /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Lo tion <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL © LEACHING FIELD K SEEPAGE PIT ❑ PACKAGE PLANT <br /> %PERMANENT ❑ TEMPORARY ❑ NEW N REPAIR ❑ 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 /> 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 /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. s <br /> 13 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in actor ce with San Joaquin County <br /> ordinances, state laws, and rul d regulati s the Sa oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ 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 /> DATENA DATE REMITTED <br /> AMOUNT � <br /> FEE `do <br /> >'� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY A <br /> OTHER <br /> OTHER <br /> Receipt No. Permit No. Iss ante a Mailed Delivered <br /> TH PERMIT/CFRVI•`FS cn�� ua�r,t .., .... ..__ -___ _-__._____ <br />