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� Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. is <br /> —APPLICATION <br /> (For Nan-Transferable, Revocable, and Suspendable) 1 <br /> ,< <br /> ENVIRONMENTAL,HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE ) <br /> Applicatio is hereby ade to car busin in the jurisdictional area of the S nn,Joa in cal Heal% District <br /> O Business (DBA) Address �! <br /> i Owner rC Address <br /> ar C `- C/ - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. 3 Telephone No. 3 Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> Applicants Name (Print) Title Date—�`��"" C <br /> Please check Applicable Category (1-7) and Fill in the Required Iniormation i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C1} 4 <br /> For July 1, June 30, 19 Disposal Sites 14 <br /> Description(Make/Yr., Color) <br /> CAL. License No. GAL. License Renewal Na. <br /> Serial No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 4 <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.G.E. No. ' <br /> Test Location Test Date/Time <br /> 4. MISANITATION PERM <br /> o?n - , -01 <br /> w.. <br /> Job Address/ ocaEion � �{ <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ElSEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 A <br /> Type Construction Disposal Site n <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 0-7 <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. <br /> hereby certify that I have prepared this lication and t the work will be done in accordance-with San Joaquin County <br /> ordinances, state laws, and rules and gul Ions of the SW�'Jqu* Local Health District.,--. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY {I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH Q"January 1 &Rece. . 1>January 31 /❑ July 1 &Received By July 31 - <br /> REMIT <br /> BASE EXPLANATION BILLING f,,t ER MITTA E .AMOUNT DUE CHECKED <br /> DATE DATE IT D AMOUNT <br /> FEE <br /> LESS <br /> PRORATION .f <br />'I PLUS <br /> PENALTY <br /> OTHER <br /> �s <br /> OTHER <br /> k% Received by Date Receipt No. Permit No. I suanc ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 E.HAZELTON AVE.,P.O.Box 2D68, STOCKTO ,CA 95201 /� <br />