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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 SEPTAGE <br /> LIQUID WASTE <br /> Applicatio Is ereby �tOrryon business in the jurisdictional area of the�n Joaquin Loo al Healt Di ri <br /> Business Name (D A _Addr ss <br /> �- ,. Address <br /> BS t <br /> a Owner <br /> a Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No.7S`�r- � Emergency Telephone No. <br /> a , <br /> 1 Contractor Licence No. <br /> LApplicants Name (Print) Title Date <br /> Please check Applicable Category (11-7)and Fill in 1 e Required 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 /> GAL. License No. CAL. License Renewal No. <br /> Serial No. `t <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 5 <br /> 4. SANITATION PERMI <br /> Job Address/ catio <br /> Owner Address <br /> 11 SEPTIC TANK ❑ CESSPOO LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW IREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 5. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <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. FL <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.. <br /> I hereby certify, that I have red this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state law nd r les d regulations the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ' <br /> br FOR DEPARTMENT USE ONLY <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEByJ my 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEES <br /> LESS <br /> PRORATION. 'r <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I Received by' <br /> Date Receipt No. Permit NO Is ane ate Mailed elivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2069 - STOCK ON,CA 95201 <br />