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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �+ <br /> i APPLICATION <br />' (For Non-Transferable, Revocable, and Suspendable) <br /> - ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE ` <br /> Appl icati is he eby ade to car on b si ss in the jurisdictional area of th San aquin Local He strict <br />'M1 Business Name (DBA) p'y[� } s� <br /> s�tt,f� Address r <br /> a Owner Address <br /> a Firm Partners, Addresses and T IephonesN�l ers <br /> CL Business Telephone No. Emergency Telephone No. a <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 <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 <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 W ) <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test ovation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/ oc ion <br /> Owner Address , N <br /> ❑ SEPTIC TANK ❑ CESSPOOL ` I EACHING FIELD +SEEPAGE PIT ❑ PACKA E PLANT <br /> ❑ PERMANENT ❑ TEMPORARY T NEWREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 C� <br /> Type Construction Disposal Site �7 g <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. ry <br /> 11 <br /> J <br /> 1 <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, an rules and r gulati f the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r <br /> v <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION } <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> - FEE <br /> LESS <br /> PRORATION <br /> PLUS �f <br /> PENALTY <br /> OTHER . - w <br /> OTHER <br /> ISS ' <br /> .� <br /> Received by - Date Receipt ND- _ Permit No- Issuance Date `Mailed Deliver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOC 6N,,CA 95201 <br /> t ' <br />