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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> I APPLICATION + <br /> -1 (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby ade to Carryon slness in the Jurisdictional area of thpS an aquin Local He Ith istri t a <br /> Business Name(DBA) t r �7• -± r AddressQ l�s� <br /> ~Owner : Address <br /> Firm'Partners, Addresses and Telef hone Numbers <br /> Business Telephone No. Emergency Telephone No. <br /> �Contractor Licence No. <br /> Applicants Name (Print) C Title ST Date �� d <br /> Please check Applicable Category(1-7)and Fill in the Required Information < <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) d <br /> i <br /> For July 1, June 30, 19 Disposal Sites t <br /> Description(Make/Yr.,Color) I <br /> Serial No. CAL•"License No. CAL. Licc;tse Renewal No. <br /> Capacity Gal.,Weights&Measures No. I <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD i <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 DateFrime <br /> 4. K SANITATION PERMIT 2A we 2 0 <br /> Job Address/ ation �1 <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW OREPAIR ❑ OTHER <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 r;For July 1,-June 30, 19 . <br /> Operator Name Where Certified <br /> Plant Location _ <br /> Plant Capacity r� No. Units Served <br /> T. ❑ LAUNDRY For July 1,-June 30, 1$ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <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, a d rules and r ulation he San Joaquin Local Health District. f <br /> APPLICANT'S SIGNATURE X �.. <br /> • FOR IDEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT, _ ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1&Received By July 31 <br /> e BILLING REMITTANCE Z REMIT t <br /> BASE EXPLAIN ON AMOUNT DUE CHECKED I <br /> DATE DATE REMITTED AMOUNT j <br /> FEE <br /> f <br /> LESS <br /> PRORATION `• - f <br /> PLUS / <br /> PENALTY 1 . _ <br /> OTHER t <br /> OTHER <br /> - W <br /> f!�f`8r7 <br /> Received by. Date It Receipt No. Permit No., Issuance Date Mailed Der ered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 ST CKTON,CA 95201 <br /> II� <br />