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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby mar c on bus, in the'urisdictional area of the San Joaquin Local alih istric <br /> rn Business Name (DBA) vie ,Addy ss <br /> 4 Owner a to Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. _y X4/,7 Emergency Telephone No. <br /> Contractor Licence No. 2 -7 <br /> L Applicants Name (Print, 11,f re i,,, Title acv In�p y 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) 3 <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal,, Weights & Measures No. <br /> Equipment Parking Address t ` <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 w (Zli. <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. _ <br /> Test Location Test Date/Time. �• <br /> 4. JM SANITATION PERMIT <br /> Job Address/Location �j pp^dllfv7 <br /> p Owner Address <br /> F SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 11SEEPAGE PIT.,, El PACKAGE PLANT <br /> G PERMANENT ❑ TEMPORARY JR) NEW ❑ REPAIR ❑ 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) <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 /> t <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, and rules <br /> and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY- ❑ PER UNIT ❑ PER SITE ❑ EAGH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE _ $ ' <br /> -BASE - EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _ Q-7 `� 7 <br /> Received by Date Receipt No. Permit No Issuance Date Mailed er erect <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �4�E.HAZELTON/VE.,P.O.Bax 2009 ST CKTON,CA 95201 d <br />