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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) SEPTAGE <br /> ." ENVIRONMENTAL HEALTH PERMIT <br /> LIQU10 WASTE <br /> Applicaxion is hereby made to ca_rry on busi ss int risdictional area of th S Joaquin Local Health Di trict <br /> H Business Name (DBA) 3 L Address O Vim, C LAy F� <br /> z Owner Address�Q �y <br /> d <br /> J Firm Partners, Addresses a T,S <br /> ephone Numbers ' <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. .— <br /> L Applicants Name (Print} Title C 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., Calor) <br /> 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 <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 /> ��Job Address/Location 4 <br /> Owner InA Address - <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGEPIT ❑ PACKAGE PLANT ° <br /> ERMANENT 13 TEMPORARY NEW REPAIR vrS❑ OTHER , <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site C1 <br /> No. of Units _ _-_. Equipment Storage/Cleaning Location(s) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 j <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. r <br /> © DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certifyhave prepared this application-%nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. d rules and re la ' ns the ta oaqu' Local ealth District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY © PER UNIT Lb PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> EASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> o f1 <br /> FEE <br /> LESS V r <br /> PRORATION <br /> PLUS <br /> PENALTY f <br /> OTHER <br /> OTHER / �f <br /> S6 0 <br /> -� y/ F­eT <br /> Received by Oate, Receipt No. Permit No Issuance Date Mailedelivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK N,CA 114 <br />