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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> Iii t (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> 1 <br /> ENVIRONMENTAL HEALTH PERMIT � <br /> LIQUID WASTE <br /> Application is h y made to on business in the jurisdictional area of the San Joaquin Local alth District_ rt <br /> w Business Name <br /> (DBA) a "-, oo� � .�, iavr Address—��8.� �40 ` V <br /> l a Owner oo�!J 1��,�Gg Address 110-T S, 4WZ j&-W! <br /> J Firm Partners, Addresses and Telephone Numbers <br /> I a Business Telephone No. 7 S" Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> L Applicants Name (Print) <br /> Title Date Io-7 <br /> Please check Applicable Category (1-7)and Fill in the Required Information 4 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 6a <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. <br /> Equipment Parking Address <br /> hL r- <br /> 2. ❑ PUMPER YARD <br /> For July 1, .. June 30, 19 <br /> f' No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> T Test Location Test Date/Time <br /> 1 4. A SANITATION PERMIT <br /> Job Address/Location f d�i�0 -- <br /> Owner �y.j &QiflSAddress <br /> 15SEPTIC TANK ❑ CESSPOOL 19 LEACHING FIELD 19 SEEPAGE PIT PACKAGE PLANT <br /> EZ PERMANENT ❑ TEMPORARY 19 NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> F <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> F B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> 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 /> ❑ DRY CLEANING, Chemicals Used/AmounVMo. <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, a ' and regulations of the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> f + <br /> FOR DEPARTMENT USE ONLY <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE 11 EACH ❑ January 1 &Received By January-31 '❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ -• REMIT <br /> BASE r EXPLANATION TE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE � <br /> I LESS i <br /> I PRORATION <br /> # PLUS t - <br /> PENALTY <br /> OTHER - <br /> OTHER. <br /> Received by Date ,. Receipt No.' - Permit No. Issu nce to Mailed 4ved <br /> F <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601-E.HAZELTON AVE.,P.D.Box 2009 STO TON,CA 95201 <br />