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J Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> x APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appl icatio Is her by ade to carry/S1?n businys in the ju isdictional area of the 5w Jo uin Local Head Distrl t <br /> Business Name (DBA) -Lef Address 1 <br /> z Owner Address <br /> C <br /> L) Firm Partners, Addresses and T le hone umbers <br /> a Business Telephone No. &� Emergency Telephone No. <br /> a <br /> -� Contractor Licence No. <br /> Applicants Name (Print) J Title ©ate <br /> Please check Applicable Category (1-7)and Fill in the Required Information f <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) f~ <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. L(c7-1se Renewal No. k <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 1 <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 /> Tt cation Test Date/Time �. <br /> 4SANITATION PERMIT 1 <br /> Job Address/LOation r <br /> Owner Address wC I <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD WSEEPAGE PIT ❑ PACKA15E PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ IN EW REPAIR ❑ OTHER ' <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site —' 1 <br /> No. of Units Equipment Storage/Cleaning Location(s) C <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified r, <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 application and that the work will be done in accordance with San Joaquin County <br /> ati s of the oa in Local Health District. <br /> state laws and ru and re ul o qU <br /> ordinances, 9 <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 13 PER SITE ❑ EACH ❑ January.1 A Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I OTHER <br /> X35 as <br /> i <br /> Received by Date Receipt No, Permit No Issu nce ate MailetlDelive d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOG TON,C 95201 <br /> I <br />