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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> ' LIQUID WASTE <br /> Appl ication i erepy mad to carry o siness in the jur' dictional area of the 5 oaqui Di <br /> ct <br /> Local Health <br /> w Business Name (DS ) Address-.. ]� 7 ��' <br /> a <br /> Owner _ <br /> Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. / 3 <br /> Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) <br /> 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. <br /> CAL. Licc,se 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 /> r <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 <br /> Job Address/L cation j D <br /> Owner Address / <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIEL BSEEPAGE PIT ❑ ACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW pAIR ❑ 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 have prepared this application and that the work will be done in accordancwih San Joaquin County <br /> ordinances, state laws, arid rules d regulations of a Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 5 <br /> 4 w <br /> FOR DEPARTMENT USE ONLY I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER ITE' --❑ EACH ❑ January,Y &R ed By January 31 ❑ July 1 &Received By July 31 i <br /> BASE EXPLANATION BILLING YREMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE { <br /> LESS V _ <br /> PRORATION <br /> M <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> A <br /> OTHER - - <br /> e <br /> Received by Date Receipt No. Permit No. Iss ce Date <br /> Delivere <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEAL PERMIT/SERVICES. 1601 E.HAZELTON AVE.,P.O. oxe2009 STOCKT N,CA 952 1 <br /> y <br />