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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign inpewp r�lo� <br /> APPLICATION Y -O <br /> For Non-Transferable,Revocable, and Suspendable) l/ <br /> ( SEPTAGE f <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to car�ryf o business n the jurisdictional area of the San Joaquin L al Health District <br /> Address— 3 <br /> F Business Name DBA) _�� ) <br /> i Owner Address QJ <br /> a <br />` u Firm Partners, Addresses and Telepho a Numbers ti <br /> a Emergency Telephone No. <br /> a Business Telephone No. <br /> Contractor Licence No. 7 ya <br /> Z Z <br /> Applicants Name (Print) <br /> elf <br /> ..r< Title Date <br /> Please check Applicable.Category (1-7)and Fill in the Required Information <br /> 1. 0,PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> r <br /> ( Description(Make/Yr.,"Col6r)). <br /> I Serial No. CAL. License No. CAL. License Renewal No. <br /> 4 : <br /> Capacity Gal.,Weights & Measures No. ) <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD - �► <br /> For July 1, June 30, 19 1 <br /> No. of Vehicles Stored ? ; <br /> No. of Chemical Toilets Stored t <br /> 3. ❑ PERCOLATION TEST z <br /> R.S. or R.C.E. Name R.S_or R.C.E. No. � { <br /> Test�ation Test Date/Time tF <br /> I 4. SANITATION PER IT <br /> I Job Address/Location <br /> k Ow r Address a-- <br /> LEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> L"J PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR 1-1 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 .+I • <br /> Disposal Site <br /> Type Construction <br /> I Equipment Storage/Cleaning Location(s) <br /> No. of Units1✓ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified F <br /> i ^J <br /> Plant Location <br /> Na. Units Served <br /> Plant Capacity <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 /> ik 4 x - _.r <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, and rul sand regulation the San Joaquin Local Healthstrict. <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 3 &ReceivedREMITuly 31 <br /> I BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE q DATE REMITTED q� AMOUNT <br /> I FEE <br /> LESS l <br /> PRORATION <br /> F <br /> PLUS <br /> PENALTY <br /> I <br /> OTHER <br /> OTHER <br /> Date Receipt No. Permit No. { suan a Date Mailed Del iv ed <br /> Received byAPPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,AYP.O.OBoy 2009 STC KTON,C 95201 <br />