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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> �s APPLICATION <br />,f 1`1 3a (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE y <br /> Zit cee4.Kr-rJ 4 il. LIQUID WASTE <br /> Applicatio 's h re y made to arty o usiness in the jurisdictional area of than Joaquin Local Health District <br /> Business Name (DBA) r Address r'C•13NC���d• -C'L F_ 20— <br /> z Owner Address <br /> a <br /> U Firm Partners, Addresses an Telephor}a Numbers <br /> IL Business Telephone No. o—gbOl Emergency Telephone No. <br /> I <br /> Contractor Licence No. "' f <br /> L Applicants Name (Print) Title Date Zed <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.. 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 ocation Test Date/Time ! <br /> 4. SANITATION PERMIT ����// �,,.`,n �c - <br /> Job Add ess/Location 5 Aio � 4"'_' Pi <br /> VV <br /> O ner� " Address Q z/_S 13 <br /> SEPTIC TANK 13CESSPOOL ElLEACHING FIELD C1SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW Y90EPAIR OTHER DJZ-4lAI SED <br /> 5. ❑ CHEMICAL TOILETS For Juiy 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 /> r <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 laws, a& rules and egulat s If the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> �r FOR DEPARTMENT USE ONLY <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT JG3 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 <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> t� S�i3 <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Deliver d <br /> APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC ON,CA 8 201 <br />