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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. S <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) –� <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE r <br /> LIQUID WASTE 'Q t <br /> Application is ereby madet carryonb ines int e]uris ietional area of the San Joaquin Local Health Distnc <br /> in–usiness Name BA) Address �,fi �'E' u 7 '� <br /> aOwner Address f�� <br /> J Firm Partners,Addresses and Telephone Numbe <br /> aBusiness Telephone No. ,�(� _-T_1��' `�_ Emergency Telephone No. <br /> Contractor Licence No. Z <br /> LApplicants Name (Print) Title Date 19— 4?- <br /> Please check Applicable Category(1-7)and Fill in the Requireg Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOA EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites �J <br /> Descriotion(Make/Yr.,Color) <br /> Serial No. CAL.License No. CAL. Licc-se 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 L cation Test Date/Time <br /> d. SANITATION PERMIT I <br /> Job Address/Location 7 <br /> Ow r Address �l g <br /> L�9,/SEPTIC TANK ❑ CESSPOOL ❑,. EACHING FIELD SEEPAGE PIT 13 PACKAGE PLANT � <br /> L� PERMANENT ❑ TEMPORARY LI NEW ❑ REPAIR Q OTHER3.4tV.0 "TitHP <br /> t. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> pe Construction Disposal Site j <br /> Iao.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 l) <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 <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 andregu Ins of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January t &Received By January 31 Q July 1 a Received By July 31 <br /> BILLING REMITTANCE <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S <br /> LESS + <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHERAL <br /> –79 -1=1-7 -7 i✓. <br /> Received ty Date Receipt No. Permit No. 19auanee to Malted Delivered. <br /> { r <br /> APPLICANT—RETURN ALL COPIES TO:• ENVIRONMENTAL HEALTH PERMITI3ERVICES•:. 1801 E.HAZELTON AYE.,P.O.0"2009 STOC&O CA, 5201' , <br /> I <br />