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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 <br /> LIQUID WASTE ,J <br /> Application is Mere ade to carry business in the jurisdictional area of the San Joaquin Lopa1 He e i Ilr� <br /> HBusiness Name (DBA Address U' <br /> aOwner Address �31y <br /> J Firm Partners, Addresses and Telephone Number zo 7'Ql <br /> CL Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. ti <br /> L Applicants Name (Print) - Title Date :.k <br /> Please check Applicable Category'( -7 and i In the Required Inf rmation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> For July 1, June 30, 19 Disposal Sites - <br /> Description(Make/Yr., Color) 1, <br /> Serial•Nb� .. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> I <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. 'I <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT '"- <br /> Job-Address/Location /V <br /> ❑ SEPTIC TANK CESSPOOL LEACHING FIEL SEEPAGE PITS ❑ PACKAGE PLANT {� <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. 0 PACKAGE TREATMENT PLANT -For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location " <br /> Plant Capacity r No. Units Served <br /> 7. ❑ LAUNDRY For July 1-June 30, <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 11 More Than 1,000 Sq" Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 <br /> i! <br /> I hereby certify that I have prepared this application and that the work will be-done in acco.rdance.•with San Joaquin County <br /> ordinances, state laws', and rules and regulati of the San Jo quin cal Health District. <br /> 3 <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 By July 31 <br /> REMIT <br /> 4 BILLING, REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEELESS <br /> PROR-AT'10N9 <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> g <br /> 7 -<:1 4 <br /> Received by Date Receipt No Permit No. Issuance Dale Mailed Delived <br /> '' - APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCATON,CA 9 201 <br />