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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication." � <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> SEPTAG;= <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> LIQUID WASTE j. <br /> Application is hereby ma a to carryon business i the j isdictional area of th n Joaquin Local Heat h Dis ; <br /> i Address <br /> NBusiness Name BA) <br /> z Owner Address : <br /> 4 <br /> 0 Firm Partners, Addre s and Telephone Num ers <br /> i` Business Telephone No. S `S Emergency Telephone No. <br /> a —� - <br /> Contractor Licence No. Date " 7 <br /> L Applicants Name (Print) ' <br /> Title r2 <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) i <br /> Serial No.. CAL. License No. CAL. Lic Ise Renewal No. <br /> Capacity <br /> A0 Gal., Weights & Measures No. V <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles StoredI; .1 �) <br /> No. of Chemical Toilets Stored �f <br /> 3. 13PERCOLATION TEST Lj <br /> R.S. or R.C.E. No. I <br /> E. Name <br /> R.S. or R.0 �•i <br /> Test Date/Time <br /> Test tion j es <br /> 4. SANITATION PERMIT <br /> Job Address/Location <br /> r Address 1-� <br /> Ow r ❑ PACKAGE�PLAi� <br /> ��EPTIC TANK 11 CESSPOOL ACHING FIELD SEEPAGE PIT ❑ OTHER ��✓Y� <br /> flet PERMANENT ❑ TEMPORARY NEW © REPAIR _ k <br /> I ----.�- <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> l Siteisposa1 <br /> Type Construction Dy [ <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> f Operator Name Where Certified <br /> f '% <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft, I <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 ru d regulations of an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I ! <br /> f FOR DEPARTMENT USE ONLY <br /> r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1,&ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE; CHECKED <br /> 1 DATE DATE REMITTED AMOUNT <br /> t <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> }[1I <br /> ` Received by Date Receipt No. Permit No. issuance Date Mailed eli eredR7 <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 _-STOCKTON CA 11 201 <br />