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Applications Will Be'Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> y (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMITSEPTAGE <br /> h ' <br /> LIQUID WASTE <br /> IAppl icatio <br /> I Business Na re by r ade ca on bus' ss int j I onal area of the S oaqui ocal Health District <br /> BAj, Address— C_-reO <br /> aOwner dress <br /> Firm Partners, Addresses and Telephone Numbers <br /> 4s <br /> Business Telephone No, Emergency Telephone No. <br /> Contractor Licence No. a <br /> L Applicants Name (Print} Title Date^ <br /> Please check Applicable Category (1-7)and Fill in theeq�red �rmalion <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRA710N (FOR EACH VEHICLE) <br /> For,July 1, June 30, 19 " - Disposal Sites . <br /> Description(Make/Yr,,Color} + <br /> Serial:No. CAL. License No. E CAL. License Renewal No. <br /> i Capacity Gal.,Weights &Measures No. . <br /> Equipment Parking Address <br /> 2. 0 PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of,Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑+PERCOLATION TEST I <br /> ii R.S.o7 R.G.E. Name R.S. or R.C.E. No. <br /> Test Location ` ' Test Date/Time <br /> 4. SANITATION PERMI w A <br /> /7M r <br /> Job Addr ss ocation <br /> Owr.•r1 <br /> O Address' <br /> 1,t��7 S PTIC TANK ❑ CESSPOOL ACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY lX NEW ❑ REPAIR ❑ OTHER _ <br /> 5. ❑ICHEMICAL TOILETS For July 1, -June 30, 19 t " <br /> Type.Construction Disposal Site <br /> No of Units Equipment Storage/Cleaning Location(s) '` P <br /> r i e <br /> 6. ;111 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ; <br /> Operator Name I' Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served ` s <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 4 }}4 <br /> SIZE: 0 Less Than 1,000 5q. Ft., ❑ 1 <br /> More Than 1,000 Sq. Ft. '' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. L <br /> ell- <br /> I hereby certify that I have prepared thi&application and that the work will be done in acc r nce ith San Joa q in County <br /> ordinances, state laws, and rules a�lations of the San Jo Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> -11 <br /> FOR-DEPARTMENT.tJSE-O <br /> #: Flee-IS DU@:.❑,•ANNUALLYp,.R,❑'PER_UNIT_,0_-yER--SITE�.! ;.❑ <br /> EAC H ❑_Ja_nuary 1 Received By January 31 -© July 1 &Received By July 31 <br /> } ; BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> t fj u. AMOUNT <br /> [ FEE C L 1 <br /> LESS I <br /> PRORATION <br /> r PLUS <br /> PENALTY <br /> O.HFR <br /> - <br /> OTHER � <br /> Received by Date Heceipt No. Permit No. =Iano ate Mailed Delivered <br /> s <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 9.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 95201 <br /> A <br />