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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 /> t <br /> LIQUID WASTE <br /> Application ' hereby ade to car on business in the jurisdictional area of the San Joaquin Local Health Distric r <br /> y Business Name (DBA) a 0— d7� S"5WWe—E- _Address 17a s'' �• AZ' ��� (lQ <br /> aOwner Address z7Qs S• �� N <br /> j Firm Partners, Addresses and Tele honeNumbers <br /> It Business Telephone No. 416 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) 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 /> 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. { <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD a <br /> For July 1, June 30, 19 <br />_ No. of Vehicles Stored <br /> No. of Chemical Toilets Stored a <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name --._ R.S. or R.C.E. No. W <br /> r. Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT (? <br /> Job Address/Location e J �d <br /> Owner � v IAZ" Address <br /> ❑ SEPTIC TANK ❑ ESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> 'PERMANENT ❑ TEMPORARY NEW ❑:REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Clean'ng Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br />. _Operator Name Where Certified <br /> i�. Plant Location t <br /> Plant Capacity No. Units Served <br /> i 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> r: SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Moir . <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 la les.and regulations of the Sa Joaquin Local Health District.." - <br /> %APPLICANT'S SIGNATURE X , #/ 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALY ❑ PER UNIT IKPER SITE © EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July-31 ; <br /> ti E REMIT <br /> ' BILLING REMITTANCE $ ' <br /> BASE EXPLANATION DATE DATE aF REMITTED <br /> AMOUNT DUE- AMOUNT +' <br /> FEE <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> s <br /> b L <br /> tS fZ <br /> Received by Date Receipt No Permit No. Issua ce Date Mailedeliver d <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.-HAZELTON AVE.,P.O.Box 2009 STOC ON,CA 95201 <br />