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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> a APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE a <br /> LIQUID WASTE <br /> Application iereby a e!o car on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business me (DBA) t Address—� '( z <br /> z Owner )_ T+ ddress 3^ ' <br /> d <br /> J Fu,_P,,Uas-,Q dresses and rTrelephone Numbers <br /> aBusiness Telephone No. iry ��� � Emergency Telephone No. �� <br /> Contractor Licence No. , <br /> Applicants Name (Print) : �"E' 1'` e�as'e' &-S Title �IF r 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, Liccnse Renewal No. <br /> Capacity ;Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. IJ 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 /> ti <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT S <br /> Job Address/Location W <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD %SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> i <br /> S. ❑ 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 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. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> . N <br /> I hereby certify that I e prepared s application and that the work will be done in accordance with San aquin ColJnty <br /> ordinances, state law nd rules an gulations a San Joaquin Local Health District. ��O <br /> APPLICANT'S SIGNATURE X JA <br /> FOR DEPARTMENT USE ONLY <br /> .Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received y ani, 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE RE I D AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> F <br /> PLUS <br /> PENALTY <br /> I <br /> OTHER I. <br /> OTHER <br /> d 3 Y� S 1 <br /> Received by - ate- f Receipt No. Permit No. - - Issuance Date Mailed Deliv ed <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO KION,CA' 5201 - <br />