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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i ereby made to carry on bu ess in the'urisd' tionai area of the San Joaquin Local Health District <br /> yBusiness Name (DB y - Address �� 7�7 ppp <br /> aOwner Address — - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) Title 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 i <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licz;lse Renewal No. r <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ^ t <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 0 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test L9cation Test Date/Time <br /> 4. El SANITATION PERMIT <br /> Job Addres /Loc ion D r <br /> Owner Address <br /> we (f-- cTcQ� <br /> EPTfC TANK ❑ SSPOOLEnrACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT j <br /> u PERMANENT ❑ TEMPORARY LTJ NEW ❑ REPAIR ❑ OTHERell <br /> �) <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 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. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> ,�/' FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY [❑ PER UNIT la PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 4, <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 39 <br /> s ? <br /> -Received by - Date Receipt No.. Permit No. )-I S1.qLraince to Mailed Deliv red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL E TH ERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST KTON,C 201 <br /> T P� ,1x711 l 1��7� l D- <br />