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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 d a <br /> LIQUID WASTE w <br /> Application is hereby made to,carry on bu ' ess in the jurisdictional area of the San Joaquin Local Health District C <br /> F Business Name {DBA)-7 Address <br /> O Address <br /> a Owner ; I <br /> Firm Partners, Addresses and Telephone Numbers <br /> o Emergency Telephone No. <br /> 0.a Business Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Titled f[- 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 /> CAL. Li <br /> Serial No. CAL. License No. cc-se RenewaLNo. <br /> Capacity ._ .- -Gal.,Weights_& Measures_No._ <br /> s <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> C>q j <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST>_ ..b ��..,, <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location h Test Date/Time_ <br /> t <br /> 4. ❑ SANITATCON PERMIT ' ` yu Pte • k <br /> Job Address/Location <br /> Owner - j ,,-,, � Address <br /> ❑ SEPTIC TANK 11 CESSPOOL UP1 EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT E] TEMPORARY 11NEW <br /> -PAIR -OTHER.. \ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _ <br /> Type Construction Disposal Site - <br /> No. of Units _ y Equipment Storage/Cleaning Location(s) <br /> 6. 13 PACKAGE TREATMENT PLANT_ For July 1, =June-30, 19 ' <br /> i ' .,Where Certified <br /> Operator Name `- -- - <br /> Plant Location �. <br />' Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 - 4 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r 3 <br /> hereby certify that I have' <br /> prepared this applicatiori..and that the work will.be-donelin accordance with SaWJoaquin County <br /> ordinances, state laws, and rule'.and egulati ns of the San Joaquin Local Health District. <br /> 1 APPLICANT'S SIGNATURE X ` <br /> 5 <br /> FOR DEPARTMENT US Y <br /> Fe Is Due El ANNUALLY ❑ PER UNIT PER SITE F-1 EACH ❑ 1 &Received By January 31 ❑ Ju1y 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING' TTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S <br /> LESSa.'� - a <br /> PRORATION , <br /> PLUS <br /> PENALTY - ".- <br /> r OTHER - <br /> fOTHER - <br /> `I <br /> y Received by - Date Receipt No. Permit No. ssuanc Date Mailed Deliver d <br /> l APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E..HAZELTON-AVE,P.O.Bo:2009 STOC TON,C 952 <br />