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App[.:ationWII 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 /> Application ispereby made to arty on business in the'uri fictional area of the San Joaquin ocal Health District <br /> WBusiness Nam DBA Address <br /> qOwner-_--ee Address <br /> J Firm Partners, Addresses and Telephone Numbers + <br /> IL Business Telephone No. D Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title -:��A`'`.''�_'�J _ Date <br /> 11 <br /> Please check Applicable Category (1-7) and Fill in the Required Information V _ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J <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. 4 <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD v ry <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored 4 <br /> No. of Chemical Toilets Stored pb <br /> 3. ❑ PERCOLATION TEST J <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. ff <br /> Test Location Test Date/Time W <br /> 4. ❑ SANITATION PERMIT I <br /> Job Addres /Location�OC <br /> / g r <br /> Ow er ����FIELD <br /> Addre /:e/eoZ 7�d"-�et _ VJ-37,I!7 SEPTIC TANK ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑'OTHER 4 <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 <br /> a <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 /> I <br /> I hereby certify that I have prepared this application-and-that the work rywill be done in accordance with San Joaquin County 1 <br /> ordinances, state laws, and rules and gulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 11 <br /> FOR DEPARTMENT USEVNYFee IS Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE 11EACH ❑ Ja S Received By January 31 ❑ July 1 8,Received By July 31 T <br /> REMIT 11 <br /> BILLING REMI TT CE $ k <br /> BASE EXPLANATION DATE DA REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE L4 s r <br /> LESS <br /> PRORATION <br /> 6 <br /> PLUS + <br /> PENALTY <br /> OTHER 6 <br /> OTHER <br /> Received by Date Receipt No. Permit No - I Issualindd Date - Mailed Deli red. -` <br /> APPLICANT—RETURN ALL COPIES-TO: -ENVIRONMENTAL HEALTH PERMITISERVICES -1601 E.HAZELTON AVE.,P.O.Box 2009 KTON,CA 95201 <br />