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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sig_n„The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application ' hereby maqe to carry o usine In he' Isdictional area of the Joaquin Local Health trict <br /> ,�Business Na (DBA) r� �=c� r54^-- Address 7� T•C� <br /> aOwners Address <br /> J Firm Partners, Addresses and Telep one Nge <br /> Un <br /> pb <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 3Z� <br /> L Applicants Name {Print) Title Date 7 <br /> Please check Applicable Category (1-7)and Fill in the Re wired Information N <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) N <br /> For July 1, June 30,°19 Disposal Sites �.. <br /> Description(Make/Yr., Color) <br /> • r <br /> Serial No. CAL. License No. CAL. Liccase Renewal No. <br /> Capacity Gal., Weights & Measures'No. <br /> Equipment Parking Address - T� <br /> 2. ❑ PUMPER HARD <br /> For July 1, June 30, 19r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> f <br /> R.S. or R.C.E. Name t R.S. or R.C.E. No. <br /> Test Location - i _ Test Date/Time <br /> 4. 11 SANITATION PERMIT i <br /> ile <br /> Job Address/Location _Z« > <br /> Owner J Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD �`��IT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR E3'0THER.� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction �' Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) ` <br /> 6. ❑ PACKAGE TREATMENT PLANT For Jiuly'l -June 30, 19 <br /> Operator Name `�' * _ here Certified <br /> Plant Location <br /> r� t <br /> Plant Capacity ��No:Units Served <br /> T. ❑ LAUNDRY For July 1, -June 30, 19 N i .1 <br /> SIZE: 1:1 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicais Used/Amount/Mo. t <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, and r and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> s <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r <br /> Received by Date Receipt No. Permit No. Issuance Daie Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P..�Box 200 STOCKTO ,CA 95201- <br /> �`"3 � 1 b�2j�� <br />