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Applications Will Be Processed When Submitted Properlycompiezeure r *�•-rr• - ` <br />-J - APPLICATION <br /> F ` {For Non-Transferable,Revocable,and 5uspendable) � F s <br /> SEPTAGE <br /> ` ENVIRONMENTAL HEALTH PERMIT <br /> r L! r LIQUID WASTE <br /> k Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health �ric;�;-ro C,) <br /> �G d �� Address A0,rn Business Name (DBA) <br /> a Owner <br /> �� ,lI,�,T/j b % Address S i+7 <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> EL Business Telephone No. <br /> a /6 6- �S�L <br /> Contractor Licence No. Date <br /> Title <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> June 30, 19 <br /> For July 1, Disposal Sites ' <br /> a Description(Make/Yr., Color) CAL. Lic- Ise Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity .Gat., Weights & Measures No.. <br /> i 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 /> 3• ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ® SANITATION PERM IT <br /> Job Address/Location <br /> Owner .4_e/41� Address <br /> NC <br /> 0 SEPTIC TANK 13CESSPOOL 0 LEACHING FIELD ® SEEPAGE PIT 13 PACKAGE PLANT <br /> E] PERMANENT ❑ TEMPORARY 1:1 NEW <br /> ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction <br /> ' No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> ► No. Units Served <br /> III, Plant Capacity <br /> 7. 11LAUNDRY For July 1,--June 30, 19 <br /> i SIZE: 11 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 d regulations of the San Joaquin Local Health District. <br /> 00, <br /> APPLICANT'S SIGNATURE X \ <br /> 9 FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT -( .PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JL;Iy 31 <br /> REMIBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE "REMITTED 1� AMOUNT <br /> FEE <br /> LESS r <br /> t PRORATION <br /> I <br /> PLUS <br /> PENALTY <br /> OTHER' <br /> OTHER- <br /> , �y 3 3 <br /> �. '�� r �� �~� is <br /> issuance Dat? Mailed Deliv ed <br /> Received by Date Receipt Nu. Permit NO. <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.BOx 2009 STO TON,C <br />