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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 `y SEPTAGE <br /> �. LIQUID WASTE <br /> Application.* hereb ad car on business in the jurisdictional area of the S n J©quirl owl Health District <br /> H Business Name (DBA) "� �V6Address <br /> a Owner I Address / 70,'T7 ,S, /� L <br /> J Firm Partners, Addresses and T/eelephone Numbers <br /> aBusiness Telephone No. [6�slc /6 Emergency Telephone No. <br /> Contractor Licence No. 362,721 r. <br /> �Applic nts'-Name-'(Prnt),-N Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. '❑�PUMPER•VEHICLE,PER_MIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, 'bF June 30, 19 Disposal Sites p^ <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 �r <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 /> Jab Address/Location ` <br /> Owner I Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ( XLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT } <br /> PWPERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ;it OTHER :4f77P <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19 <br /> Type Construction Disposal Site <br /> r <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For-July 1 -June-305l 9 <br /> Operator Name Where Certified <br /> Plant Location I�r <br /> Plant Capacity No. Units,Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 I <br /> SIZE: El Less Than 1,000 Sq. Ft., More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> !t <br /> 1 ; <br /> kf <br /> I hereby certify that I have prepared this application and that the'work will lie done in accordance"vvith-Sant Joaquin County <br /> ordinances,=state laws, a les and re ula.ions of th San Joaquin Local Health District. <br /> CAPPLICANT'S 51GNATURE X t <br /> � I t <br /> _ v ` FOR DEPARTMENT USE ONLY ti <br /> Fee Is Due: ❑ ANNUALLY OtiPER,UNJ PER SITE ❑ EACH_;❑ January 1 &Received By January 31 �❑ July 1 &Received By July 31 <br /> s <br /> BILLING REMITTgNCE� $ y �L REMIT <br /> BASE EXPLANATION i AMOUNT DUE CHECKED <br /> E DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> L OTHER <br /> 71zj lYl'— <br /> Received by - Date Receipt No. Permit No. Issuance Dae Mailed Dell1lered <br /> i, APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM_IT/SERVICES 1601 E.HAZELTON AVE.,P.O:Box 2009 STOC 95201 <br />