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f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION �Y. <br /> F h i (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> i ,LIQUID WASTE <br /> r Application In b a e to c siness in the jurisdictional area of the Joaq Local ealt istrict <br /> r rn Busines a 'DBA '1 Addres C <br /> r 4 Own Address `_ _ <br /> Firm Partners, Addresses a elephone Numbers XkCAL <br /> IL Telephone No. '' Emergency Telephone No. <br /> adc " <br /> Contractor Licence No. <br /> Applicants Name (Print) >E. Title 1'l�e Date �"`►��" <br /> Please check Applicable Category�11-7)and Fill In the Required Information oya <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. ill CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &.Measures No. <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 /> f' 3. []'PERCOLATION TEST i <br /> R.S. or R.C.E. Nam _-- R.S. or R.C.E. No. <br /> Test Location I Test Date/Time <br /> i <br /> k; 4. @91SANITATION PERMI,Tp� <br /> Job Address ovation 924A� <br /> Owner Address ISA <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD &SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT. ❑ TEMPORARY ❑ NEW 9YREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For'` my 1, -June 30, 19 <br /> Type Construction Disposal Site _ <br /> No. of Units !I[I Equipment Storage/Cleaning Location(s) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> I Operator Name Where Certified h <br /> i Plant Location <br /> Plant Capacity III y No. Units Served ' <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> .11 <br /> SIZE: ❑ Less Than 1,000 Sq. It., ❑ More Than 1,000 Sq. Ft. <br /> f ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I ' <br /> i <br /> II <br /> hereby certify that I hav�rs <br /> this appli nd that the work will be done in accordance with San Joaquin County <br /> j" ordinances, state laws, nregulatio Joaquin Local Health District. <br /> I <br /> APPLICANT'S SIGNATURE X <br /> l: <br /> 4° <br /> I SII FOR DEPARTMENT 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 /> REMIT <br /> ,.. BASEBILLING REMITTANCE $iI EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE— 1G <br /> PRORATION PRORON IIS <br /> L PLUS II <br /> PENALTY <br /> i OTHER <br />{ <br /> OTHER <br /> i �9-'91A1 9nL's.-7 � <br /> Received by Date I Receipt No. Permit No Issuance Date Mailed Relive d <br /> I. <br /> APPLICANT—RETURN ALLCOPiS TO: ENVIRONMENTAL HE TK PERMIT SVIGS 16 1 E.HAZEL ON AVE.,P.O.Boz 20 SOC TON,C <br /> V. `f -7 ®w 1 <br />