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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 /> r LIQUID WASTE <br /> Application is reby made to carry on business in the jurisdi tional area of the San Joaquin Local Health District \ <br /> y Business Name (DB ) Address ] I <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. c. �> Emergency Telephone No. <br /> Contractor Licence No. ?_. 4 <br /> L Applicants Name (Print) <br /> Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C� <br /> For July 1, June 30, 19 Disposal Sites ry <br /> Description(Make/Yr., Color) r ' <br /> Serial No. CAL. License No. CAL. Lfoz:nse Renewal No. � <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 _ F <br /> No. of Vehicles Stored <br /> IE <br /> No. of Chemical Toilets Stored _1 <br /> 3. ❑ PERCOLATION TEST r <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time M1 <br /> 4. ❑ SANITATION PERMIT 3 <br /> Job Address/Locatio I a <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CES <br /> L LEACHING FIELD IT ❑ PACKAGE PLANTA <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER 1 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> t <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ 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 •1 <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 /> ji <br /> ordinances, state laws, and rules and gulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> { FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT <br /> 'PER SITE ❑ EACH ❑ January 1 &Received By January 31. ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT r <br /> I DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ) AMOUNT <br /> FEE <br /> 5 yS t� <br /> LESS <br /> PRORATION 1 <br /> PLUS = <br /> PENALTY t <br /> OTHER <br /> OTHER 1 <br /> Received byDate Receipt No. Permit No. <br /> I swan Date Mailed De ivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH.PERMIT/SEERVII]CESS 1601 E..HA1ZELTON AVE.,P.O.Box 2009 .ST.00KTO ,CA 95201 <br />