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d Properly <br /> Applications Will Be Processed When Sub�mPittPeLICAT'ONCompleted.Be Sure To Sign The Application. <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> 2�� ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> + - � <br /> made to car on business the jurisdictional area of th �rn,loaq�uin Local He Ith District <br /> Application is hereby�� � � ^. Address �r <br /> y Business Name (DBA) Lam/ Address <br /> ,Y <br /> a Owner 1 <br /> U Firm Partners, Addresses and Telephonep,Numbers <br /> Emergency Telephone No. <br /> IL Business Telephone No. ���-- r,. Date <br /> �- _ <br /> Contractor Licence No. c' Title�� , � L,� <br /> Applicants Name (Print) <br /> Category (1-7)and Fill in the Required Information <br /> Please check Applicable <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR ECS eVEHICL <br /> For July 1, Disposal <br /> June 30, 19 _--- <br /> CAL. License Renewal No. <br /> Description(Make/Yr.,Color) CAL. License No. <br /> Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity <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 /> 3, ❑ PERCOLATION TEST R.S.or R.C.E.No. <br /> R.S.or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. L+t"`SANITATION PERMIT <br /> Job Addre s/Location Address— 13 PACKAGE PLANT <br /> Own ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> L"7 SEPTIC TANK ❑ NEW C�'"�REPAIR <br /> O PERMANENT ❑ TEMPORARY <br /> 5, ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Disposal Site , <br /> Type Construction Equipment Storage/Cleaning Location(s) <br /> No. of Units June 30, 19 <br /> Where Certified <br /> g. ❑ PACKAGE TREATMENT PLANT For July , - <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity _ <br /> 7, ❑ LAUNDRY For July 1, -June 30, 9 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 1More1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> re ared this application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that0hap p Mations a Sa oaquin"Local Health District. <br /> ordinances, state lawides an g <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ER SITE ❑ EACH REMIT <br /> PER UNIT CHECKED <br /> Fee IS Due: ❑ ANNUALLY ❑ BILLING REMITTANCE $ AMOUNT DUE AMOUNT <br /> BASE EXPLANATION DATE DATE REMITTED <br /> FEE <br /> LESS <br /> PRORATION ! <br /> PLUS \ <br /> PENALTY <br /> OTHER 'S <br /> OTHER <br /> fa c� Ci Mailed Deliver � <br /> VPermit No. ssuan a Date 1 <br /> Received by <br /> Date Receipt No. 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,CA <br /> APPLICANT—RETURN ALL COPIE&TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />