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c � Applications Will Be Processed When Submitted Properly Completed. 13e Sure To Sign The Application. <br /> APPLICATION <br /> .a (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is h reby made to car isd <br /> on siness i the j ictional area of the San oaq Local Health District J <br /> Business Name A) -r4 Address .v v ;;1,914 OwnerA4V, Address 17 <br /> Firm Partners, Addresses and Telephone Numbers <br /> a p Business Telephone No. <br /> Emergency Telephone No. <br /> Contractor Licence No. 2— <br /> Applicants Name (Print} Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required 1�formafil�.. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites 4\ <br /> Description(Make/Yr., Color) V <br /> Serial No. CAL, License No. CAL. Lic;.Ise 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.SZorRG Name R.S.or R.C.E. No. <br /> Tesn Test Date/Time <br /> 4. TATION PERMIT <br /> Job Address/Loc io Q <br /> O,wA-- <br /> per a Address .r ]�Jr /� <br /> Lam, STI TANi{ CESSPOOL ACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> Le"PERMANENT ❑ TEMPORARYi NEW 13 REPAIR 11 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) tj <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 I <br /> r <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- i <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 1 <br /> ordinances, state laws, and rules and r 5!:51ions of the San J uin LocaF Health District. ; <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT OPER SITE ❑ EACH. ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 4 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �/ AMOUNT <br /> FEE 7 r ` Cj, <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> R <br /> OTHER Y <br /> OTHER [ ii <br /> 7 <br /> � 3t13 <br /> Received by Date Receipt No. - Permit No, Issuance Date - Mailed Delivered- <br /> APPLICANT—RETURN <br /> eliveredAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVIces <br /> 1601 E.HAZEL�QN�A,V r,P.O.Box 2009 STOCKY ,CA 5201 <br />