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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 SEPTAGE ) <br /> LIQUID WASTE <br /> App lic is�reby made to carry on bu est in the jurisdictional area of the San Joaquin Loca Health District 1 <br /> ,„Business Name (DB,A)) tlOT U/C� Address S. 4� -6 �T J <br /> aOwner& GUr Lri-C.-Y_ Address/292-5- <br /> 03 <br /> ddress -5-03 Firm Partners, Addresses and Telephone Numbers <br /> IL a Business Telephone No. �S ro fia Emergency Telephone No. <br /> _J Contractor-Licence;No. <br /> Co <br /> L IPr. 1� ',`� <br /> a Applicants Name <br /> (Print)'— <br /> {Print)'- r Title ST, Date ` <br /> Please eck chAppiicabre Category(1-7)and Fill in the Required Information <br /> I. El 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, License Renewal No. <br /> Capacity Gal., Weights & Measures No. i <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 /> -¢ <br /> 3. 11 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. 0 SANITATION PERMIT <br /> Job Address/Location a l -0 P4 <br /> Owner E Address <br /> � �r E <br /> �+ SEPTIC TANK ❑ CES POOL %LEACHING FIELD WSEEPAGE PIT ❑ PACKAGE PLA T <br /> PERMANENT ❑ TEMPORARY Whi ❑ REPAIR ❑ OTHER <br /> 5.' ❑ CHEMICAL TOILETS For July 1,k June 30, 19 <br /> Type Construction Disposal Site r <br /> No. of Units Equipment Storage/Cleaning Location(s)" <br /> i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 = ' <br /> Operator Na me # Where Cern�ed"'� - <br /> Plant Location <br /> Plant Capacity } No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 3 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., I❑ More Than 1,000 Sq. Ft. d <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo, <br /> ZFAI A <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with SaiJoaquin County <br /> ordinoes, state laws, r s and regulations of the San Jo uin Local Health District. # <br /> APPLICANT'S SIGNATURE X ! > - _ , <br /> ...- - - •FOR,DEPARTMENT-U$E ONL-Y---- <br /> f <br /> Fee Is Due: ❑ ANNUALLY- ❑ PER UNIT I PER SITE ❑ EACH ❑ January l &Received By January 31 ❑ July T &Received By July 31 <br /> BILLING REMITTANCE $ HEMIT <br /> [. BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED - <br /> AMOUNT <br /> FEE 4 <br /> LESS 1 <br /> PRORATION fv) n <br /> PLUS <br /> PENALTY <br /> OTHER ? f <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Dae Mailed Deliv red - <br /> APPLICANT-RETURN AL-L',COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,1601 E.HAZELTON AVE.,P.O.Box 2009 STO KTON CA 95201 <br />