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Applications'Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> j APPLICATION <br /> M (For Non-Transferable, Revocable, and Suspendable) I <br /> '�— ENVIRONMENTAL HEALTH PERMIT SEPTAG> V/ <br /> LIQUID WASTE l <br /> Applicati hereby madg to carry on business in the jurisdictional area of the San Joaquin Local Health Distict �� 1 <br /> Business Name (DBA) e(" .S�%{�ylC� Address <br /> aOwner Address ��� S• � C>, <br /> Firm Partners, Addresses and Telephone Numbers <br /> r <br /> a Business Telephone No, Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> Applicants Name (Print) a Title 5 + Date d� } <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) i <br /> i <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> t <br /> Capacity 'I Gal.,Weights & Measures No. s <br /> Equipment Parking Address <br /> I i <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 E <br /> No. of Vehicles Stored I <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST f0 s <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. <br /> Test Location Test Date/Time <br /> r-- <br /> 4. J9 SANITATION PERMIT " <br /> Job Address/Locatio <br /> Owner E 'C Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ;K SEEPAGE PIT <br /> CD PACKAGE PLANT <br /> PrPERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER CA <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 O� <br /> :I <br /> Operator Name Where Certified "r <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. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> l� <br /> ii <br /> �i <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 laws, anc rul s d regulations the,an oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> -a <br /> i) <br /> le FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ii ❑ PER UNIT ® PER SITE ❑ EACH ❑ January 1 &Received By January 31 Cl July 1 &Received By July.31 <br /> REMIT <br /> BASE ' EXPLANATION BILLING REMITTANCE $ ,AMOUNT DUE CHECKED. <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS " <br /> i PENALTY �I <br /> r -� <br /> OTHER i <br /> OTHER 5 <br /> 6 5Co1 (-(130 J16 4� <br /> Received by - Date.I - Receipt No. - Permit No. Issuanc Date Mailed Deliver. <br /> APPLICANT—RETURN ALL COPIES TO:, ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK iON,CA 9,201 <br />