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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For <br />�.. (For Non-Transierable, Revocable, and Suspendabie) <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 /> .n Business Name (DBA) � ''� Address <br /> z Owner "��% 42,,rJ4 � � Address <br />� a ' <br /> J Firm Partners, Addresses and T, ephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> -�Contractor Licence No. <br /> Applicants Name (Print) a Title —,,,� ��� Date R' <br /> Please check Applicable Category(1-7) and Fill • the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i <br /> For July 1, -- June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> I, >: Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <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 7 [ <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time `- ` <br /> 4. 13 SANITATION PERMIT <br /> �o 5 <br /> Job Address/Location / f�G <br /> rS <br /> ��EACHI��GF <br /> AddressTICTANK ❑ CESSPOOL IELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> MANENT ❑ TEMPORARY W ❑ REPAIR ❑ OTHER <br /> _ <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 i <br /> Type Construction Disposal Site { <br /> -No. of Units Equipment Storage/Cleaning Location($) <br /> 4; 6, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 1 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> j 7. 11LAUNDRY For July 1, -June 30, 19 <br /> i SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ii ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r <br /> 1 i+� � ,� f► w R <br /> r <br /> p 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 r ulations of the San,Joaquin Locai'Health District" > .7b. <br /> f ,APPLICANT'S SIGNATURE X <br /> ,FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE- ❑ EACH ❑ January 1 &Received By January 31 #❑"'JuVy 1 &Received By July 31 <br /> REMIT <br /> I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> . .y t BASE EXPLANATION DATE DATE" REMITTED AMOUNT <br /> --.. <br /> FEE <br /> LESS S <br /> PRORATION <br /> PLUS <br /> PENALTY s <br /> OTHER <br /> .OTHER— <br /> Received by Date Receipt No Permit No. Iss ante ate Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES To. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZ£LTON AVE.,P.O.Box 2009 STOCKTOI CA 9 <br />