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r ✓f 'Applications Will Be Processed When Submitted Properly Completed, BeSureTo SignTneApp11ca110r1. <br /> ` APPLICATION <br /> i (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE / <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> r A. F�lJ�.2/S S��fS � x <br /> y Business Name (OBA)— �� Address d <br /> x Owner Address <br /> a <br /> k_ � Firm Partners, Addresses and Telephone Numbers <br /> $ Business Telephone No. p Emergency Telephone No: <br /> Contractor Licence No. <br /> Applicants Name (Print) Fyr� — Title Date °n <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. Licc�se Renewal Nv. <br /> r <br /> Capacity Gal., Weights &Measures No. <br /> fA <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ` <br /> P <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> TTest Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location E CO/Ln1 F <br /> F Owner A [-1J 2 Address <br /> SEPTIC TANK ❑ CESSPOOL ` LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> k <br /> PERMANENT C1TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> K 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 fr <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> x 6. 13T PACKAGE TREATMENT PLANFor July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> t Plant Location <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 /> j ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I t . <br /> E <br /> ,I 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 rules and regulations of the S — aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> yc,� <br /> 1 FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER c - <br /> OTHER <br /> Received by ate Receipt No. PerMtT NO. l suanc Date Mailed Deliv ed 7 <br /> - <br /> STO TON, A9520 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAXELTON AVE.;P.O.Bok 2009 L " <br />