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APPLICATION <br /> Non-Transferable, Revocable, and Suspendablf <br /> ENVIRONMENTAL HEALTH PERMIT `� D� SEPTAGE <br /> LIQUID WASTE <br /> Application is her by ads to carryon uslness in the jurisdictional area of thPDAan aquin}ocal He Ith istrl t <br /> F Business Name (DBA) W j � Addressl 0• 1K f1�-�� .i- o Ls71I <br /> i Owner .Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Aa. Business Telephone No. Emergency Telephone No. <br /> j Contractor Licence No. J? <br /> Applicants Name (Print) O ! Title Dates <br /> Please check Applicable Category(1-7)and FIII In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) G <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 <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> 0. IK SANITATION PERMIT T.C) �' T 2/' <br /> Job Address/ ation <br /> Owner Address <br /> ❑ SEPTIC TANK CESSPOOL <br /> LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER <br /> cu <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 e <br /> Type Construction Disposal Site G <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 /> 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 d rules and r ulations he San Joaquin Local Health District. <br /> 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 $BASE EXPLAN?ONDATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE y <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 1 11 <br /> _ <br /> Recanted by Dale Receipt No. Permit No. Issuance Dare Mailed Del' erect <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa T009 ST CXTON,CA 85301 <br />