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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT S�PTAG <br /> LIQUID WASTE <br /> Applicatto reby a to rry o usinesstin the jurisdictional area of the San Joaquin Local Hea ct <br /> OF Business Name (DBA Add r O �► <br /> z Owner Address-/1710 <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ass a� t Emergency Telephone No. - <br /> Contractor Licence No. 09 IF <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information f <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. CAL. License No. CAL. Licc,se Renewal No. y <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 f <br /> 4. SANITATION PERMIT L4 <br /> Job Addres ocati , <br /> Owner Address E '�' <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PL NT <br /> PERMANENT ❑ TEMPORARY ❑ NEW WFIEPAIR WOTHER <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 <br /> Plant Location Veyi <br /> Plant Capacity No. Units Served <br /> I <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 /> A <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County l <br /> ordinances, state I les and regula ons of th an Joaquin Local Health District. <br /> 6 R <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 S Received By July 31 <br /> REMIT <br /> KILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DU£ CHECKED <br /> }� AMOUNT <br /> FEE S (rE <br /> LESS <br /> PRORATION <br /> PLUS 1 i <br /> PENALTY <br /> OTHER I <br /> OTHER <br /> 0-� Ot-7 9 13 0 a <br /> _ <br /> Received by Date Receipt No. Permit No I*wancle Date Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11601 E.HAZELTON AVE.,P.D.Box 2009. STOC ON,C 95201 //// <br />