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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> #,- (For Non-Transferable, Revocable, and Suspendable) f <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> ' LIQUID WASTE <br /> Application is hereby made to carry q usiness in the jurisdictional area of thSan Joaquin Local Health District <br /> yBusiness Name (DBA) Address_, Q <br /> aOwner Address <br /> J Firm Partners, Addresses andele h ne Numbers <br /> a Business Telephone No. 87 7 �, Emergency Telephone No. 1_ <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information —5) <br /> I. ❑ 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 Renewal 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. ❑ SANITATION PERMIT <br /> Job Addres /Location r N <br /> Owner /� �� Address' !!/ Lr <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLA6T <br /> O` <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR P-6THER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site Cl <br /> No. of Units Equipment Storage/Cleaning Locafion(s)---' <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified13 <br /> Plant Location ` 1 <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 application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT' SIGNAT 2 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 Juiy 31 <br /> BASE EXPLANATION MILLING REMIT <br /> REMITTANCE $ AMOUNT DUE CHECKED <br /> f DATE DATE REMITTED AMOUNT <br /> FEE tt' s t`I C <br /> LESS 7 J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 14E r-2- <br /> 1 OV <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 160 E.HAZELTON AVE.,P.O.Box 2009 STOCKT 201 <br />