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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTA15HEAL.TH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (D A) Address <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. �5 Emer ency Telephone No. <br /> Contractor Licence No. 7el If <br /> 7Z s," <br /> L Applicants Name (Print) a Title hfr 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. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST r <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. 11 <br /> Test Location Test Date/Time <br /> Q E <br /> 4. Z SANITATION PERMIT <br /> Job Address/Loca . n �a2O� Lt"v /l�l/h✓S (/�-' Ifi .� rrca <br /> Owner 16 lin aILA Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT Ef PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 'KNEW ❑ REPAIR ❑ 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 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 /> hereby certify that I have p ared this application an hat the work done in accordance with San Joaquin County <br /> ordinances, state laws, a ul s alai regu ions th an Joaquin al ealth District. <br /> APPLICANT'S SIGNATURE + <br /> FOR DEPARTMENT USENLY <br /> Fee Is Due: 1:1L1 ANNUALLY ❑ PER UNIT PER SITE El EACH nu ry 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> {REMIT <br /> BASE EXPLANATION BILLING TT.;.,,,C,E $ AMOUNT DUE CHECKED <br /> DATE TE REMITTED AMOUNT <br /> FEE <br /> LESS — <br /> PRORATION -- _ <br /> PLUS — <br /> PENALTY <br /> OTHER <br /> OTHER <br /> s 3s C 100 <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Deliv ed <br /> ^ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES {691 E.HAZELTON AYE.,P.O.Box 2004 STD KTON, 93 1 is ,fir`/ M <br />