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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION , <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMEWrALAEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati is hereby ade to carry n business I he jurisdictional area of the San Joaq Local Health istrict <br /> ,Business` me (DBA) " '_ �� -�N.2 Imo. Addre .�' <br /> aOwner Address <br /> Firm Partners, Addresses and Telepho�+ne Numbers <br /> a . HBusiness Telephone No. c'��r 33 Emergency Telephone No. SIJ • <br /> Contractor Licence No. © 4S"U1 <br /> LApplicanis Name (Print) _ t WG do Title 0WAIe9— Date Jz'/62-7.4-N%-, <br /> Please <br /> 2-7.4-N%- <br /> Please check Applicable Category (1-7)and Fill in the Required Information w <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July,1l, 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 r <br /> 2. ❑ PUMPER YARD -Y-J <br /> For July 11, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PiRCOLATION TEST _ <br /> R.S. or R!C.E. Name R.S. or R.C.E. No. <br /> Test L cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addres Locgtion f3AR •� L '4'�`�' �'� <br /> Owner Address C <br /> OW SEPTIC TANK ❑ CESSPOOL ffLEACHING FIELD R-SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ 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: ill Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have pre are <br /> this plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and Sand re of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 15r PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE e r s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> y. <br /> OTHER <br /> i <br /> Received by Date Receipt No. Permit No. issuance Date Mailed liver d rf / <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON A P.O ox�,2 9 TOC ON,C 95201 /j/ <br />