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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) <br /> ENVIRONMENTAL. HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE .a <br /> Application•is7hereby made to carry on business in the jurisdictional area of the San-Jqoaquin L cal Health District r I <br /> Business Name.(DBA) Address <br /> i Owner--/ r Address _ 9-Y.3 <br /> J Firm Partners, Addresses'a'nd Telephone Numbers <br /> aBusiness Tel`epho7l`rlq '~'��—"'-Emergency Telephone No. t <br /> Contractor Licence No. <br /> L Applicants Name(Print) rr Title h P 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. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD j <br /> For July 1, June 30, 19 1 <br /> No. of Vehicles Stored <br /> i <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. fh 1, <br /> Test Location Test Date/Time (,) <br /> 4. ❑ SANITATION PERMIT _ // <br /> Job Address/Location 5� '4e'kv- o <br /> Owner r`+' Address vL� <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ` <br /> I-PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER fvm A,4x10 �r} I <br /> 5. d CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> � <br /> B. ❑ 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. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. i <br /> I hereby certify that I have prepared this application and that the work will be done in accorda with San Joaquin County <br /> ordinances, state laws, and rules nd regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> to <br /> FOR DEPARTMENT USE ONLY <br /> f ; <br /> Fee Is 011e: ❑ ANNUALLY PER UNIT PER SITE ❑ EACH IElJanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 11 _ b_3�( k, � <br /> Receive� !DeT Receipto. Permit No.- Issuance at� Mailedroe <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC TON,C 95201 <br />