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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r. (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application-is her by made to carry on bus ss In the jurisdictional area of the Saps Paquin Local Health District <br /> F Business Name (DB ) --J Address �, c J -� -- <br /> z Owner 401`cwGG c:dZ Address w <br /> Firm Partners, Addresses and Telephone Numbers <br /> � <br /> i a Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> a � <br /> L Applicants Name (Print) E "e,�-• �✓ Title ��—.__.�� Date ��-- <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <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. iL% <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 TESTYa- <br /> R.S. or R.C.E. N a ":. . . ._� .: RS:-or R.C:E: Nom <br /> Test Location .}F Test Date/Time 3 <br /> 4. ❑ SANITATION PERMITk� <br /> Job Address/Location "` <br /> O,,wnn `r Add ess ..,.. d. t � <br /> Ie SEP71C TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE-PLANT j <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ',. ��❑ REPAIR. ❑ OTHER~~ Z_ F <br /> 5. ❑ CHEMICAL TOILETS or July 1, -June 30 19 `-`g �'� •`,''- ,�:�,�> - ---• - �� 4 �, � t <br /> Type Construction ';`DisposalSite <br /> No. of Units TEquipment Storage/Cleaning Location(s) 4. <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t <br /> Operator.Name _ _, Where Certified 1 <br /> - <br /> Plant Location <br /> s <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. f p <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 4 <br /> i <br /> i I hereby certify that I have prepared this application and that the workwill be done in accordance with San Joaquin County <br /> j ordinances, state laws, and,rules and re I ation f the San Joaquin Local•'Heaith"District. <br /> APPLICANT'S SIGNATURE X`, `�� -• � #' a� <br /> 7 <br /> .-.4: ` FOR-riEP_ARTMENT USE ONLY <br /> !: ., - ` <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT❑{PER-SITE ❑-EACH :�-January_1'.8`_Received By January 31- ;❑ Juiy 1 &Received By July 31 <br /> -�_ •r" `�' r,,. 1REMIT- BILLING REMITTANCE $ <br /> BASF EXPLANATION AMOUNT DUE CHECKED <br /> _DATE DACE 1r REMITTED � f AMOUNT <br /> FEE... LA - rr .i <br /> LESS <br /> PRORATION "r r <br />'. PLUS <br /> r <br /> _,..PENALTY <br /> OTHER 30 d <br /> Received by' Date Receipt No Permit No Issuanclp Date Mailedred <br /> APPLICANT—RETURN ALL COPIES40- ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601.E.HAZELTON AVE.,P.O.Boa 2009 S OCKTON,CA� <br />