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APPLICATION <br /> rr Non-Transferable, Revocable, and Suspendab"I" <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application isl�7lhere��`{made to arry on b�}�'iness in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name (DBA) <br /> p,�z ea l �� Jd.t7j Address; <br /> z Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Z,(- 57,607 Emergency Telephone No. <br /> Contractor Licence No. _ <br /> Applicants Name (PrinF)fid! 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. 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 Location Test Date/Time <br /> 4. )0 SANITATION PERMIT <br /> Job Address/Location a <br /> Owner Address -- <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY '❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -�a <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) r <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 /> 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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X_;��-l2a;e <br /> FOR DEPARTMENT USE ONLY <br /> j Fee IS Due: ❑ ANNUALLY ❑ PER UNIT CRIPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE 5 <br /> BASE EXPLANATION DATEDATE REWTTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEEIL <br /> C' 'Xryn <br /> LESS <br /> PRORATION 47,i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No [Issual Date Mailed elivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,CA 9 <br />