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+ p <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> r - LIQUID WASTE <br /> I Application is hereby m to carry on business in the jurisdictional area of the Sart Joaquin Local Health District <br /> rn Business Name (DBA) G' DQ Addresses 405 14 R-,P7_ <br /> aOwner �° Address_jQs�i � <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> iContractor Licence No, 3 <br /> L Applicants Name (Print) Title �� Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information„ <br /> 4 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> C For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) ` <br /> i Serial No. CAL. License No. CAL. License Renewal No. Q <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address } <br /> 2. ❑ PUMPER YARD <br /> f. For July 1, June 30, 19 <br /> No. of Vehicles Stored r <br /> .No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E, No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> A <br /> `Job Address/Location <br /> Owner Address1 <br /> 10 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD '� SEEPAGE PIT ❑ PACKAGE PLANT <br /> KPERMANENT ❑ TEMPORARY 9NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br />.L 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; ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 910% <br /> I <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, an es and regulations of the an Joaquin Local Health District. <br /> 4, <br /> APPLICANT'S SIGNATURE X <br /> p� FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNT. �v PER SITE ❑ EACH ❑ <br /> January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ _ REMIT <br /> is DATE DATEREMITTEQ AMOUNT DUE CHECKED <br /> FEE r AMOUNT- <br /> LESS J <br /> LESS I = ' <br /> PRORATION 1F y <br /> PLUS <br /> PENALTY <br /> OTHER L �` <br /> OTHER <br /> -- 1 11 t' I <br /> Received 6y Qate Receipt No. ermt o. I uanc Date Mailed Deliv red <br /> APPLICANT—RETURN ALL•COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.'.P.O.Bos 20D8 STO KION,CA 95201 <br />