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nppneauurrs <br /> ,.A upany % V111peeio!u. or au <br /> t� APPLICATION u 019+1 Sit!nppiecauvu.era <br /> (For Non-Transferable, Revocable, and Suspendable){ ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i yhereby made o parry on busin ss in the jurisdictional area of the§Aq Joaquin Local Health District <br /> v,;;�'usiness Name (DBA) Ad ress <br /> P <br /> . iwner Address <br /> A <br /> (-�,rirm Partners, Addresses and Telephone Number <br /> a Business Telephone No. —3 - SI Q S Emergency Telephone No. <br /> :ontractor Licence No. <br /> applicants Name (Print) = Title Date f. <br /> Please check Applicable Category (1-7) and Fill In the Required Informs an <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> IIor July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> i erial NO. CAL. License No. CAL. Licc ase Renetival No. <br /> apacity Gal., Weights & Measures No. <br /> equipment Parking Address <br /> r 2. ❑ PUMPER YARD <br /> i -or July 1, June 30, 19 <br /> FNo. of Vehicles Stored <br /> VNo. of Chemical Toilets Stored <br /> F ❑ PERCOLATION TEST <br /> ,-..S. or R.C.E. Name R.S. or R.C.E.No. <br /> 'Nest Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT 7 y t ` i+�� <br /> Job Address/L cation y� W. <br /> Flown <br /> ,, r Address <br /> i �t�'�8'EPTIC TANK ❑ CESSPOOL ACHI G FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑'PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> f No. of Units Equipment Storage/Cleaning Location(s) �r <br /> F6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 {vnt <br /> -i"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 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 rul and regulatie-0 th Joaquin Local Health District. <br /> M I APPLICANT'S SIGNATURE X � <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑.ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ 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 /> r f������1 <br /> i�'i FEE <br /> LESS <br /> li PRORATION <br /> PLUS <br /> OTHER PENALTY 4/X it <br /> OTHER <br /> OTHER <br />�. F _ <br /> Received by Date Receipt No it Nd. Iss ance a I Mailed Delivered <br /> 4 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZELTON AVE.,P.Ot Bjoa f009 STOC�I.TON,CA 95201 <br />