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F <br /> . Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ' APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) / SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 1 <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District r, <br /> O Business Name (DBA) Addr ss <br /> aOwner. . �qZ1Address <br /> Firm Partners, A dresses and Telephone Numbers <br /> aBusiness Telephone No: - d Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) � Title _.. , Date <br /> Please check Applicable Category•(14)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July T, _= June 30, 19-"- - Disposal Sites I <br /> DescriptiW(Make/Yr., Color) , r- <br /> Serial No. CAL. License No. ' CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address >*V <br /> 2. 11 PUMPER YARD1( a'. - a ; <br /> For July 1,'_ June 30,':19 <br /> i h <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. © PERCOLATION TEST 'rF a , st.� <br /> R.S. or R.C.E. Name t' ;1 R.S. or R.C:E.No. ;.�. <br /> Test Location; Test Date/Time <br /> 4.SANITATION PERMIT <br /> Js/Location <br /> ob Addres <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL 54 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT. <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW Pt REPAIR ❑ OTHER ' <br /> 5. ❑ CHEMICAL TOILETS ForeJuly 1, -June 30, 19 <br /> Type Construction z Disppsal.5ite <br /> No. of Units" i - Equipment,Storage/Cleaning Location.(s)e <br /> 6. ❑ PACKAGE TREATMENT PLANT'Fdr July 1; June 30,'19'" """� <br /> Operator Name a Where Certified <br /> Plant Location' <br /> Plant Capacity � No. Units Served <br /> •7. ❑ LAUNDRY For July 1, -'June 30, 19 A <br /> SIZE: ❑ Less Than 1,000 Sq.-Ft.—, - IT More_Than 1,000 Sq. Ft.� <br /> ❑ DRY CLEANING;Chemicals Used/Amount/Mo.�.r <br /> Y . <br /> I hereby certify;that I,have prepared this application'and that the work will be done in accordance with San Joaquin County <br /> -m <br /> ordinances, state laws, and r es and re ulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURCX v v r i <br /> F -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 BILL-ING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE ITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION } <br /> PLUS } <br /> PENALTY Al <br /> i <br /> OTHER I 4 <br /> OTHER <br /> - X_5 <br /> Recei d by Date Receipt No. - Permit No. Issuance Date <Mailedl Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O. 009 STOCKTON,CA 85201 <br /> 4 <br />