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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ?fi ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati I S,bt, by QadEUI.o carry on usiness in the jurisdictional area of the San Joaquin Local He ct <br /> yBusiness N m (DBAddress <br /> z Owner ` ��` Address `7a� c�• /� �L�&�r <br /> a <br /> J Firm Partners, Addresses and Telhose tubers <br /> aBusiness Telephone Na. �s �o Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. 0 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. Licc tse 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. SANITATION PERMIT 0 3 y ��� .Q <br /> Job Addre /Location Q <br /> Owner Address (� <br /> 0 SEP TANK El CESSPOOL 13LEACHING FIELD 13 SEEPA E PIT ❑ P CKAGE PLANT <br /> X PERMANENT ❑ TEMPORARY X NEW ❑ 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 /> I hereby certify that I ha repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state law , a lesland regulations f the Sa J quin Local Health District. <br /> APPLICANT'S SIGNATURE X ' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PEH SITE ❑ EACH ❑ January 1 &Received By January 31 I] July 1^&Received By July 31 <br /> t REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE. CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Y� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> b sas C � <br /> Received by Date Receipt No. - Permit No, Issuan a Date'- Zild D liver d <br /> APPLICANT—RETURN ALL COPIES-TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AVE.,P.O.Box 2009 STOCK 0 <br /> N,-CA 201 <br />