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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Translerable, Revocable, and Suspendable) '4-.SEPTALGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE . <br /> Appl icatio hereby made to carry on business A the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name (DBA) �V Oa � IC.C- Address240,5 - <br /> a Owner_ � �iCC� Address ® -� <br /> Firm Partners, Addresses and Telephone Numbers <br /> / <br /> a. Business Telephone No. 7 4S_ R C/ Emergency Telephone No. <br /> Contractor Licence No. - <br /> L Applicants Name (Print) - Alipi Title Date `-a <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 /> 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, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored W <br /> 3. ❑ PERCOLATION TEST 1v1� <br /> R.S. or R.C.E. Name _t R.S. or R.G.E. No. "3 <br /> Test Location Test Date/Time <br /> 4. $SANITATION PERMIT �^ <br /> Job Address/Location ?.3 .P-W-e <br /> Owner o E—LAC) Address— <br /> SEPTIC TANK TANK ❑ CESSPOOL EFLEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY PKNEW ❑ 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 /> 1 <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, a s and regula 'ons�of th San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> T <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT La PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received ByAuly 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> k� DATE DATE REMITTED1. AMOUNT <br /> l FEE S Y <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY �A <br /> OTHER <br /> OTHER <br /> - <br /> Received by - Date Receipt No. Permit No. ltsuancb Date Mailed Del' ered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITYSERVICES 1601 E.-HAZELTON AVE.,P.O.Box 2009 ST CKTo"CA 95201 <br /> v � a <br />