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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application: X--0436[) <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br />{ LIQUID WASTE ^� <br /> Appiica,', is reby de to r on b in in he jur'sdictional area of the San Joa in tical He t�Dist t <br /> r � Ad ess Zig <br /> N usiness Name (DBA) <br /> z Owner Address <br /> a <br /> r Y Firm Partners, Addresses and T ephone Numbers <br /> 4 a Business Telephone No. _ - !!a - Emergency Telephone No. <br /> I Contractor Licence No. <br /> Applicants Name (Print) 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, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc^se 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 /> t R.S. or R.G.E. Name R.S. or R.C.E. No. <br /> r Test Location Test Date/Time <br /> 4. SANITATION PERMIT• /'7f`r�_! �, <br /> Job Address/ ooation +(/ !U <br /> } Owner Address en 747 Gi <br /> 4 ❑ SEPTIC TANK ff CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> K PERMANENT ❑ TEMPORARY ❑ NEW PirREPAIR ❑ 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) _j <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 VA <br /> Operator Name Where Certified <br /> ° Plant Location <br /> I 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 /> i <br /> ' I hereby certify that I have prepared this application and that the work-will be done in accordance with San Joaquin County <br /> ' ordinances, state 1 an ru and regulations of the San J a uin Local.Health District. <br /> l � , <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 /> DATE DATE REMYTTED AMOUNT <br /> FFEE <br /> i LESS <br /> PRORATION <br /> PLUS L <br /> I PENALTY <br /> OTHER !� <br /> OTHER V <br /> 4 <br /> Received by- Date Receipt No. Permit o. Issuance Date Mailed Deliv red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTDN AVE.,P.O.Box 2009 STO KTON,C 9520 <br /> f <br />