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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> + (For Non-Transferable,Revocable, and Suspendable) y <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> 1 LIQUID WASTE <br /> F y on <br /> Application is hereby made to carrbusiness in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) <br /> Owner Address <br /> J Firm Partners,Addresses and Telephone Numbers Address <br /> a Business Telephone No. tr/ <br /> ' -1 Contractor Licence No. 7 Emergency Telephone No. <br /> C <br /> L Applicants Name (Print) Title ! <br /> o Date <br /> Please check Applicable Cate <br /> g ry (1-7)and Fill in the Required Information <br /> 1 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. License Renewal No. <br /> Capacity Gal),'Weights & Measures No. <br /> i <br /> Equipment Parking Address <br /> f 2. ❑ PUMPER YARD <br /> For July,1, <br /> June 3Q, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION-TEST <br /> R.S. or R.C.E. Name <br /> R.S. or R.C.E. No. <br /> Test Location ., y <br /> 4. ❑ SANITATION PERMIT - Test Date/Time �. <br /> Job Address/Location <br /> f <br /> Address 3 <br /> SEPTIC TANK C1 CESSPOOL ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br />` ❑ PERMANENT-"' ❑ TEMPORARY ❑ NEW <br /> I 5. ❑ CHEMICAL5TOILETS For July 1, -June 30, 19 11 REPAIR ,ax ❑ OTHER <br /> I <br /> Type Construction-- t ' = _ <br /> Disposal Site <br /> No. of Units r Equipment Storage/,Cleaning_Locations) <br /> 6. ❑ PACKAGE-TREATMENT PLANT For "" io - t <br /> Jul 1 - <br /> Operator Name a <br /> Y June 30, 1� <br /> Plant Location' <br /> Where Certified t <br /> Plant Capacity6 I <br /> ' "'No-tJn i ts-Served <br /> 7. ElLAUNDRY'�'For.July.1.,yJune.30, 19 A-- <br /> SIZE: ❑'Less Than i,000 Sq. Ft., ❑ `More Than 1,000 Sq:F_t. <br /> El DRY CLEAN ING,"Chemieals`Vse'd/A ount/Mo. <br /> a ti r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance w tI San Joaquin County <br /> ordinances'State laws;and rules and regulat' <br /> 109ftsoft San Jo quirt Local Health District: <br /> APPLICANT'S SIGN <br /> ATC1113E <br /> s <br /> y FOR DEPARTMENT USE ONLY s <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT Ql PER SITE <br /> ❑ EACH <br /> t ■ ❑ January 1 &Received By January 31 ❑ July T &Received By July 31 _ <br /> i BASE EXPLANATION BILLING REMITTANCE $ - REMIT <br /> DATE DATE REMITTED - AMOUNT DUE- CHECKED <br /> FEE ©C AMOUNT <br /> LESS 7 VVI <br /> PRORATION - <br /> PLUS j <br /> PENALTY j <br /> ,OTHER <br /> O-TitER <br /> --fib a 3 <br /> Received y Date Receipt No. <br /> Permit No. Iss ante D to Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH p.ERMI /T 5ERifl'CES <br /> 1601 E:HAZELTON AVE.,,P.O.Box.20095TOCKTON;,CA 95261 <br />