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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 <br /> Applicatio is hereby mj�de to carry o b sines5 i he jurisdictional area of the San Joa in Local Health District <br /> rn Business Na (DBA) LZ ``*' Z Address �� <br /> aOwnerAddress f <br /> Firm Partners, Addressesand elephone Numbers <br /> CL <br /> Business Telephone No. rr!! Emergency Telephone No. <br /> Contractor Licence No. os <br /> OF <br /> Applicants Name (Print) l Title N tit"'" - Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑, PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL, Liccae Renewal No. <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 <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. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERT <br /> Job Addres /Location <br /> Owner Address �- <br /> R-SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -9Une 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. I <br /> f" <br /> I hereby certify that I have prep red this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws s regulations of than Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> J 1�, FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> BILLING REMITTANCE $ REMIT - <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION r <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ante Date Mailed gDeltTOred <br /> APPLICANT—RETURN ALL COPIES.TO: .ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009- STON,CA <br /> � f A <br />