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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 he eby de to c r on busines n the junsd'ctional area of theSan J quin Local Health istric <br /> NBusiness Name (DBA) Lam, r �ts?, K�r� �4ddress <br /> z Owner Address <br /> C <br /> Firm Partners, Addresses and T 1 Zn Numbers <br /> ILBusiness Telephone No. Q Emergency Telephone No. <br /> Contractor Licence No. 011 <br /> LApplicants Name (Print) 6 Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q' <br /> For July 1,_ June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <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,T 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 /> Te t cation Test Date/Time <br /> 4. SANITATION PERMI <br /> Job Ad e s ca io <br /> Owne Ca4OL, Address Z '� <br /> ❑ 11SEPTIC TANK SSPOOL LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> �{ ^ , <br /> '+PERMANENT ❑ TEMPORARY ❑ NEW REPAIR %OTHER LXM1-fV5'4J^f> <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> L <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) OF <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 I have prepared thi application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ales and re ulatio o he SnLaquin Local Health District. <br /> r <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE I ❑ EACH ❑ January 1 &Received By January 31 0 July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED OUNT DUE CHECKED <br /> AMOUNT <br /> FEE r Z� <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date MailedVVI—ivereyr <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCK ON,CA 9/201 <br />