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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APfa IC414"TION , <br /> (For Non-Transferable, Revocable, and Suspendable) 1 <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE S <br /> Application is ereby ma to carry on business in the jurisdictional area of the San Joaquin Local H Ith Distriv <br /> rn Business Name (DBA) a?� Address 0 � !yC cl�41._t -_J ) <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> .� <br /> aBusiness Telephone No. 6o y"" :O 77 <br /> C Emergency Telephone No. <br /> Contractor Licence No. l $7 <br /> LApplicants Name (Print) ��- rn .✓ Title � 't C'1" Date <br /> Please check Applicable Category(1-7) and Fili1ln the Required Information <br /> � <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) A <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, gSANITATION PERMIT <br /> Job Address/Locati n 6YI <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR VOTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 f/tdS fI^U�r lm� of (�dlK <br /> Type Construction Disposal Site <br /> { <br /> No. of Units Equipment Storage/Cleaning Location(s) I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified 41 <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> } <br /> I hereby certify that I have prepared this applicatio and that the work will be done in accordance with San Joaquin County <br /> ordinances, state la s, and rules nd jeffitilati ns a San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> - Fee Is Due: ❑ ANNUALLY ❑ PER UNIT WIPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July.31 - <br /> BILLING REMITTANCE $ REMIT } <br /> BASE EXPLANATION g <br /> DATE , DATE REMITTED I AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS !� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> f'D I 5 , <br /> 3r k <br /> Received by Date Receipt No. Permit No. Issuan Date Mailed eli red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> - . - - 1601 E.HAZELTON AVE.,P.O.Box 9 ST y'KKTON; A 8,5201 y <br />