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Applications Will Be Prt.wvsed When Submitted Properly Completed.Be S�e�o Sin The Application. 1 <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE, <br /> Applicatio Is her b ade to car n bu ' ss i e jurisdictional area of.the San Joaquin oc 1 Health Distric <br /> y.Business Name BA)�� Address L �7 e' <br /> z Owner A dress <br /> 1 <br /> �.Firm Partners.Addresses and Telephone umbers <br /> Business Telephone No. -AMIF.I?:-,!� jr : E,,,,_,,,,,_,ncy Telephone N_ <br /> I <br /> Contractor Licence No. v � 1 <br /> L Applicants Name (Print) <br /> Title �s....�� 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 /> Serial No. 9_ CAL. License No. CAL.License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address• 0 <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30, 19 M <br /> No. of Vehicles Stored TK <br /> No.of Chemical Toilets Stored . C <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. :Q SANITATION PERMIT <br /> Job Address/Location ( C <br /> Owner Address ^' <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD '❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY `Q 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. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30,.19 <br /> Operator Name Where Certified 1 <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDAY •For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. V <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 1_hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rules an regulations of.theSa oaquin o I He Ith istrict. <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 /> BASE EXPLANATION •BILLING' REMITTANCE g - REMIT - <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE'. <br /> LESS <br /> PRORATION' <br /> PLUS <br /> PENALTY ' <br /> OT}IER <br /> {K <br /> OTHER - <br /> RBCeived'by ate Receipt NPermit o. ailed eliv ad <br /> 'Issuance Dee Mt <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Bow 200y STO TON,CA 95 <br />