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1 <br /> IS <br /> Applications Will Be Processed When Submitted Properl;�to`mpleted. Be Sure To Sign The Application. ` <br /> ' APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> Z. ` ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on businas.in the juri dictional area of the;,San Joaquin Local ealth Di <br /> s <br /> Business Name-(DBA) fP1rP �lr+' Address <br /> OwnerT14 �{ _U� Address r <br /> u Firm Partners, Addresses an clephone Numbers <br /> aSusir ess Telephone No. _ Emergency Telephone No. <br /> I Contractor Licence No. <br /> Applicants Name(Print) L"_ ��, �, i` I l N _ _ Title Date— <br /> Please check Appllcable 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 _ I 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 b R.S. or R.C.E.No. <br /> �. <br /> Test Location Test Qafe/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/ cation <br /> Owner Address <br /> ❑'SEPTIC TANK C1CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY ❑ NEW 11 REPAIR ❑`OTHER 1. i <br /> 5" 11 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction } Disposal Site f f <br /> No.of Units Equipment Storage/Cleaning Location(s)_ 1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 JJJ <br /> Operator Name _- _ Where Certified <br /> Plant Location <br /> r -- <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 /> S <br /> 1 <br /> I 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 J`cjuin Local Health District. <br /> APPLICANT'S SIGNATURE X q <br /> FOR DEPARTMENT USE ONLY , <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE : ❑ EACH ❑ January I&Received By January 31 ❑ July 1 &Recewed By July 31 <br /> tREMIT <br /> BASE EXPLANATION BILLING REMITTANCE S 4 AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT !� <br /> FEE - <br /> LESS — <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ? OTHER <br /> OTHER <br /> Received by Date q Receipt No. Permit No.� Issuance Date Mailed. Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O,Boy 2009 . BTOCK70N,CA 95201 <br />