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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 /> Application erpy made car i tsiness jurisdictional e S <br /> al area of than Joaquin Lo al Health District <br /> Business Nam ( BA) 1210_15� in <br /> lin e jurisdiAddress <br /> aOwner w Le_ Address <br /> Firm Partners, Addresses and <br /> f�Telephone`Numbers <br /> J <br /> a Business Telephone No. 7_Gh d e. Emergency Telephone No, <br /> Contractor Licence No. 46 <br /> L Applicants Name (Print) — Title Date ! <br /> Please check Applicable Category (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 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address 1 <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 PERMIT <br /> Job Address/Location 4c <br /> Owner o94ZI Address 3aZbf <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 19.SEEPAGE PIT ❑ PACKAGE PLANT <br /> (PERMANENT ❑ TEMPORARY JZNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 6' <br /> No. of Units Equipment Storage/Cleaning Location(s) -G <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location _ <br /> - f <br /> Plant Capacity No. Units Served - <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 f l <br /> SIZE! ❑ Less Than 1,000 Sq. Ft., ❑More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r <br /> I hereby certify that I have p red this app' n and t t the work-will-be done in accordance with San Joaquin County <br /> ordinances, state laws, an les <br /> rid <br /> gul ons the S Joaq Local Health District. <br /> APPLICANT'S SIGNATURE X r <br /> ® i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> $ REMIT <br /> BASE EXPLANATION BILLING REMITTANCE-., , AMOUNT DUE CHECKED <br /> DATE —,DATE REMITTED 4642- <br /> AMOUNT_ <br /> FEE ys - - - 14 <br /> LESS <br /> PRORATION v�' O V - <br /> PLUS <br /> PENALTY vV / <br /> OTHER <br /> OTHER'- i <br /> Received by" Date Receipt No Permit'No. Issuace D to Mailed Delivered. 'y <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZ AYE.,P.O.Boc 2009-TSTOCKTON,CA 95201 <br />