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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Y-� APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SPTAGE } <br /> ~} J ENVIRONMENTAL HEALTH PERMIT . <br /> / LIQUID WASTE <br /> l <br /> busine n the jurisdictional area of the Sa u oval alt istr' t <br /> Applica�fio�h eby ma car <br /> i <br /> rBusiness me (D13 ) Addre <br /> a Owner <br /> Address D <br /> J Firm Partners, Addresses an legbone ijlumners <br /> aBusiness Telephone No. Si (� Emergency Telephone No. <br /> Contractor Licence No. �.y <br /> L Applicants Name (Print) Title Date Q <br /> I, 1 <br /> Please check Applicable Category (1-7) and Fill in the Required Information ( F <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,- June 30, 19 Ii Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> IP <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 rt <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. of R.C.E. No, <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMI <br /> Job Address/ Ca c <br /> aim <br /> Owner - Address a <br /> SEPTI ANK ❑ C SPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLA <br /> PERMANENT ❑ TEMPORARY 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) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ! <br /> -- Where Certified` <br /> Operator Name4 <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 .'e <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. f <br /> { <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I Have pr red this application and that the work will be done in accord a with San Joaquin County <br /> ordinances, state laws, and nd regula ' ns f the S Joaquin Local Health District. <br /> 9 � <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: C3ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ Jan ary 1 ceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMIT AN E $ AMOUNT DUE CHECKED <br /> DATE D E REMITTED AMOUNT <br /> FEE I <br /> o- <br /> LESS t <br /> PRORATION - <br /> i <br /> PLUS <br /> PENALTY <br /> , <br /> OTHER <br /> OTHER - <br /> Received IsyDate Receipt No. Permit No. _ Issuance Date Mailed a Ivere - , <br /> -. APPLICANT—RETURN ALL COPIES TO: '�:ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Box 2009 .STOCK N,CA.9 <br />