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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 /> SEPT.AGE <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> LIQUID WASTE <br /> Applicatio 's h reb m de to carry n sin i t e j ictional area of the Sanoa uir"ecal i rict <br /> �j G <br /> OF Business Na e D J Address ` ' t' <br /> z Owner ddress I I <br /> 4 <br /> J Firm Partners, Addresses and Telephone Number <br /> aEmergency Telephone No. <br /> a Business Telephone No. <br /> Contractor Licence No. <br /> � <br /> Applicants Name (Print) Title Date �dd <br /> Please check Applicable Category (1-7)and Fill in the Required Int rmation 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> i <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. t(� <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 Cb <br /> No. of Vehicles Stored ' QQQ, <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 I Test Date/Time <br /> F <br /> 4. ❑ SANITATION PERMIT <br /> Job Ad ess/Loca ' n <br /> Owner Address <br /> 13 SEPTIC TANK ❑ CESSPOOL 13 LEACHING FIELD ❑ SEEPAGE PIT El PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site t <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 k ; <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 Or <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. = <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t t <br /> 4-, 5 <br /> I hereby certify that I have prepared this application at'the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a n lations of th San oaquin Local Health 'strict <br /> APPLICANT'S SIGNATURE X <br /> _ FOR DEPARTMENT USE ONLY <br /> E Fee IS Due:_❑',ANNUALLY El PER UNIT LA PER SITE EACH ElJanuary 1 &Received By January 31 ElJuly_;1 &,Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE AMOUNT DUE-?; 'y CHECKED <br /> BASE EXPLANATION <br /> -4 DATE DATE REMITTED .''.'-AMOUNT <br /> FEE <br /> Gl- <br /> LESS <br /> aPRORATION <br /> F ' PLUS <br />�-- PENALTY , <br /> OTHER ' <br /> OTHER <br /> -7 o lD 7 <br /> Received by Date Receipt No. Permit No- Issuance Date -.Ma'iled _elive d <br /> fAPPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2004 �STOC TON,C 11201 <br />