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r Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTneAPPHcallDn <br /> APPLICATION <br /> - " (For Non-Transferable, Revocable,and Suspendable) <br /> r SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> C ' <br /> Address <br /> yBusiness Name (DBA) <br /> z Owner �- Address <br /> 4 <br /> J <br /> Firm Partners, Addresses and Telephone Numbers ; <br /> Emergency Telephone No. <br /> IL Business Telephone No. <br /> Contractor Licence No. ¢ Date <br /> LApplicants Name(Print) <br /> U�� Title <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 <br /> Description(Make/Yr., Color) CAL. LizzF se Renowal No. <br /> Serial No. CAL. License No. _ r <br /> Capacity - - - Gal.,Weights& Measures No. <br /> Equipment Parking Address i M <br /> 2. ❑ PUMPER YARD < i — <br /> For July 1, ' June 30, 197 a <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST y <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name - <br /> Test Location f Test Date/Time <br /> 4. ❑ SANITATION PERMIT J <br /> Job Address/Location <br /> 6 Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT 11 PACKAO HERGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY I] NEW EPAIR - .El <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal-Site, <br /> r Equipment Storage/Cleaning Locations)"" <br /> No. of Units - 4 <br /> r" 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,'19 <br /> Where Certified , <br /> 4 Operator Name �. <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> ) 7. ❑ LAUNDRY For July.1•,.,:,.June 30-19 --- <br /> SIZE: <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq, Ft. I <br /> ❑ DRY CLEANING, Chemicals Used/Amount/.Mo. rt <br /> EE (' <br /> i. <br /> I <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 "gul s of the San Joaquin Local Health District. <br /> li; au- <br /> APPLICANT'SSIGNATUREX <br /> J. <br /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT [5 PER SITE C1EACH 13January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> �. BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE Y REMITTED li AMOUNT <br /> �` <br /> FEE S 4 <br /> LESS,, <br /> PRORATION <br /> PLUS -\ r F w �' * .k ✓ <br /> PENALTY i \ <br /> OTHER <br /> L <br /> OTHER <br /> Received by Date Receipt No. Permit No "Issuance Date Mailed Delive d <br /> �- - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1 jai E.HAZELTON AVE.,P.O.Boz 2009. STO TON,CA 201 <br />