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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Si n The Application. <br /> APPLICATION � <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAG� <br /> LIQUID WASTE p-� �- y� f <br /> Applicati n is herloymade t arty,o usiness in the jurisdictional area of the an Jo uin Local Heal istrict <br /> ,„Business meJDBA) Addres <br /> z Owner t Address <br /> I r <br /> Firm Partners, Addresses and Telephone Numbers F <br /> a. Business Telephone No. 3� Emergency Telephone No. Ste•- ��� <br /> Contractor Licence No. Q <br /> �Applicants 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. Liccnse Rencwal 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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. EW SANITATION PERMIT - <br /> Job Add r ss/Lgcation O` <br /> Owner Address 41, S,A^A., - <br /> ErSEPTIC TANK ❑ CESSPOOL LEACHING FIELD P SEEPAGE PIT ❑ PACKAGE PLANT <br /> IIPERMANENT ❑ TEMPORARY 'WNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <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. <br /> I hereby certify that I have prepared applicatio d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules a gulations of e n aquin Local Health 4st(,it1t. <br /> APPLICANT'S SIGNATURE X <br /> 4V <br /> FOR DEPARTMENT U <br /> Fee Is Due: E3 ANNUALLY ❑ PER UNIT PER SITE 13 EACH ❑ ar 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REM NICE $ REMIT <br /> BASE EXPLANATION AMOUNT DATE TE REMITTED DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> C7_' (� o <br /> Received by Date Receipt No Permit No. - ssuanceDate AMailed De Ivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAjE4� E �f2909 STOCK ON,CA 95201 <br />