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- :.. - - <br /> Applications Will Be Processed When Submitted Property Completed Be Sure To Sign The Application. <br /> . I' APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> gI LIQUID WASTE <br /> Busines <br /> t Applicatio is re ! m to�rSrry on bus ess i t jurisdictional area of the n Joaquin Local Health District <br /> rn e.(DBA) �( <br /> aOwner /� Address <br /> Address <br /> I Firm Partners, Addresses an <br /> Tie 'hone N 11 m bers .Z l <br /> aBusiness Telephone No. ' <br /> -1 Contractor Licence No. Emergency Telephone No. <br /> Applicants Name (Print) tck< ,c�, 1 <br /> Please check Applicable Category Title 4 — Date �r�. <br /> g ry(1-7) and Fill in the Required Information I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ' <br /> For July 1, June 30, 19 G' Disposal Sites <br /> Description(Make/Yr., Color) :� ? <br /> Serial No, <br /> CAL. License No. CAL. License Renewal No. <br /> Capacity :ilial., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> g <br /> No. of Chemical Toilets Stored li ; <br /> 3 ❑ PERCOLATION TEST I' <br /> R.S. or R.C.E. Name'- II J <br /> R.S. or R.C.E. No: <br /> Test Location •,. <br /> a• SANITATION PERM T Test Date/Time <br /> Job Addres cation <br /> Ow er <br /> JJ�� Address a <br /> ! y�EPTIC TANK 11CESSPOOLI1 LEACHING FIELD O � <br /> 'SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORAR,Y 'ANEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction II Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30 19 <br /> t <br /> Operator Name 'll <br /> Plant Location Where Certified f <br /> Plant Capacity l <br /> 7. ❑ LAUNDRY For July 1,.-June 30, 19 No. Units Served <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., I ❑ More Than 1,000 Sq. Ft. � Q <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. `�+L <br /> I hereby certify that I have'rpre this applicatio nd th <br /> ordinances, state laws, and r es. the work will be done in accordance with San Joaquin County <br /> an reg tions of a oaquin Local Health District. 4 <br /> APPLICANT'S SIGNATURE X <br /> I�: I <br /> 11! FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jul I <br /> y &Received By Jufy 31 I <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> EEE AMOUNT 4 <br /> LESS <br /> PRORATION I <br /> PLUS J <br /> PENALTY <br /> OTHER y ! <br /> OTHER .i <br /> Received by Date iE _ Receipt No Permit No, s <br /> APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMIT/$ERVICE5 - 5suan a ate Mailed Delivered <br /> •1501 E.-HA2ELTON AVEP.O.Box 2009 - <br /> ' l _ <br />