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*1Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> 10 APPLICATION T <br /> endable) <br /> (For Non-Transferable, Revocable,and Susp <br /> ,.� .t. SEPTAG <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> m Business Name (DBA)—12 A. PAAddress O o <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers . <br /> a Business Telephone No. Emergency Telephone No. <br /> 4 <br /> V_J Contractor Licence No. . <br /> -I[ Applicants Name (Print) <br /> L y7 11CF Title _ Date <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Un <br /> For July 1, June 30, 19 Disposal Sites <br /> k` Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License 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. No. <br /> R.5. <br /> or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. .V SANITATION PERMIT <br /> Job Address/Location .,, <br /> Owner Address '? <br /> ❑ JASEPTIC TANK CESSPOOL LEACHING FIELD A SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> r <br /> ' S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 D <br /> Type Construction J Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> ( Where Certified <br /> Operator Name <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 /> k <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 rules and regulations of the S oaquin Local Health District. <br /> i <br /> APPLICANT'S SIGNATURE X <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &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 /> y� <br /> LESS <br /> ¢¢¢ PRORATION <br /> PLUS <br /> { PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit NO: R Issuance Date Mailed Deliv red <br /> 55201 <br /> APPLICANT-RETURN ALL COPIES TO: : ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> . 1601 E.HAZELTON AVE:,P.O.Bay 2009 -' '3T KTON CA <br /> I. - <br />