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ApplicationsWillBeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r � r <br /> � .: APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEFTAGE <br /> LIQUID WASTE <br /> Applicatio is h e made to c ry on b iness in the jurisdictional area of than aquin Local Heaith (strict <br /> Business Name (DBA) Address—M, J <br /> zz Owner Address <br /> Firm Partners, Addresses and T Iep hone/Numbers 3 <br /> aBusiness Telephone No. Ya- to6 Emergency Telephone No. <br /> Contractor Licence No. i <br /> Applicants Name (Print) e Title <br /> Date r <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 RerGwal 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 cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Locati <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT s <br /> PERMANENT ❑ TEMPORARY NEW 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 this a I' ation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rules n e ul ions of n J03qu' cal Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 'PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received Eiy July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT pUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS �t <br /> PRORATION <br /> PLUS —0-0 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I suance Date Mailed �Dever <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HATELTON AVE.,P.O.Box 2009 <br /> 'TOC <br /> TON,CA 1111 <br />