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Applications Will Be Processed When Submitted Properly Completed. Be Sure -To Sign The Application. y <br />l - APPLICATION <br />(For Non -Transferable, Revocable, and Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT SEEPAGE <br />LIQUID WASTE <br />Appl icatio hEjreby m aiwo carQoon bus' ss in the idrisdictional area of the San JoaquinLo I Heal Di is <br />y business N e DB ) Addr oz - <br />aOwner,2 Address <br />j Firm PartnersAddresses resses and Tele hone Numbers <br />IL Business Telephone No Ste— 6 f 6 <br />a Emergency Telephone No. <br />Contractor Licence No. <br />LApplicants Name (Print) zff <br />Title Date" <br />Please check Applicable Category (1-7) and Fill in the Required Information <br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July 1, June 30, 19Disposal Sites <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 <br />3. ❑ PERCOLATION TEST <br />R.S. or R.C.E, Name R.S. or R.C.E. No. <br />Test Location i Tes Date/Time <br />4. XSANITATION PERMIT ye— <br />Job Address n <br />Owner Address <br />SEPTIC TANK ❑CESSPOOL ❑LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br />PERMANENT ❑ TEMPORARY ❑ NEW XREPAIR ❑ 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 f 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. FL, ❑ More Than'1,000 Sq. Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br />_ 1 <br />I hereby certify that I hav ed this application a that <br />ordinances, state laws, d ru deregulations of an Jo <br />APPLICANTS SIGNATURE X �f1� <br />work will be done in accordance with San Joaquin County <br />1 Local Health District. <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 />DATE DATE REMITTED AMOUNT <br />FEE <br />LESS f� I ► t <br />PRORATION 1 <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date Receipt No. Permit <br />– APPLICANT—RETURN ALL COPIES TO:; ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />X <br />Issuance Date Mailed - Deliver d <br />1601 E. HAZELTON AVE., P.O. Box 2009 STO TON, C 5201 — <br />