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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati r y madto carry o In s the jureictional area of the San aguin L �eaj y,�i�sttrict +� <br /> ,F Business Nam BA) AV <br /> � ��� R Address l �I �ACCII <br /> z Owner �1 Address <br /> 4 <br /> j Firm Partners, Addresses and e e Numbers <br /> aBusiness Telephone No. Emergency Telephone No, <br /> Contractor Licence No. <br /> Applicants Name (Print) "�%At A '' Title Date <br /> r��� <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 /> Contractor Address License No. Phone <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 n <br /> Job Address/Location x7, `g <br /> Owner /7 VC-y Address S9 M2+� <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ® REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 rke <br /> Type Construction Disposal Site fi 6 <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 /> I hereby certify that 1 have prepared this application an that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the$at Joaquin Local Health District. <br /> , <br /> APPLICANT'S SIGNATURE X 2 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By duly 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS / <br /> PRORATION r <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dato Receipt No. Permit No, Issuance Date Mailed Delive d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 $TO TON,CA 201 <br />