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rw Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION ` OI <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGi= <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is,,Ppreby made to carrydn.business in the jurisdictional area of th an J aquin Local Health Qistri r <br /> 07Business Name (DBA) rS sSl"S. 2'�'JC - .Address S <br /> z Owner ..Address <br /> M Firm Partners, Addresses and Tielle h ne Numbers <br /> a. --9,66 Business Telephone No. Ti�� ,7 Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name(Print} d Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information r,�� _ r , <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) .� <br /> For July 1, "-.June 30, 19 Disposal Sites = t <br /> Description(Make/Yr., Color) C <br /> Serial No. $ CAL, License No. CAL. License Renewal No. f;1 <br /> Capacity'r 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 f f <br /> 3. ❑ PERCOLATION TESTi <br /> R.S. or R.C.E. Name R.S. or,,R.C.E. No. . <br /> Test cation _ Test Date/Timet <br /> 4. 1p1SANITATION PERNAT, <br /> Job Address/jL cation Z <br /> Owner Address . <br /> 5E IC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑,{ PA KAGE PLANT <br /> ao <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR'S 1! OTHER J?le4 -VO( +t}D w <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ;, ,i �„• .' <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 l <br /> Plant Capacity -0 Units Served ! R <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. �'' <br /> _ F <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> r . I hereby certify that I have,prepared this application and that the work will be done in accorda'ice with San Joaquin County <br /> d rules and r gulatio f the S n Joaquin Local Health District. <br /> ordinances, state laws, a <br /> APPLICANT'S SIGNATURE X 4 <br /> vz s <br /> 6 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER-UNIT ❑ PER SITE " ❑ EACH ❑ Janua�y'1 &Received By January 31. © July 1 &Received8y July 31 ' <br /> REMIT <br /> BASE EXPLANATION BILLING MITTANCE $ Am6uO T D�1E_ ! 4 CHECKED <br /> DATE DA�rE REMITTED r" AMOUNT <br /> 1.0} <br /> FEE '� •• ff kI iF <br /> �6 <br /> NX <br /> LESS <br /> PRORATION Ilk <br /> . <br /> PLUS � <br /> PENALTY a - <br /> OTHER <br /> OTHER <br /> ANI <br /> Received by 'Date . Receipt No. a k Permit No y` Issuance Date ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Boa 2009 STOCKTTOON,CA 95201 <br />