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APPLICATION <br /> !For Non-Transferable,Revocable,and Suspem �) <br /> ENVIRONMENTAL HEALTH PERMI D� SEPTAGE <br /> LIQUID WASTE <br /> Application is her yga�de�to c�arrryo,�n, p`�us`m-e_ss in the jurisdictional area of th an aquin ocal He Ith Istri t <br /> Business Name (DBA) b -I"�q ! 4�Address �• �-�0 <br /> i Owner _.Address ng if <br /> Firm Partners, Addresses and Telephone Numbers it rV <br /> K Business Telephone No. u� -4��� Emergency Telephone No. <br /> Contractor Licence No. �- -JZ <br /> Applicants Name (I Lk 11 a I e I Fa --Title ST Date 20 <br /> Please check Applicable Category (/-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 0 <br /> For July 1, June 30, 19 Disposal Sites t <br /> Description(Make/Yr., Color) --_ <br /> Serial No. CAL. License No. __ CAL. Liccnse 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 /> 4. Ig SANITATION PERMIT �� <br /> Job Address/ tion W'/TT <br /> l/ <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 11 SEEPAGE PIT 13 PACKAGE PLANT <br /> PERMANENT 13 TEMPORARY NEW REPAIR El OTHER <br /> ev <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 C <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/AmounVMo. <br /> 1 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 ulation 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/a Received By January 31 ❑ July 1 8 Recetsed By July 31 <br /> REMIT <br /> BASE EXPLANAON BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> IYDATE DATE - REMITTED ,! AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> 64 <br /> PLUS <br /> PENALTY <br /> OTHER (J <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed "er.WdAPPLICANT—r101JAN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 <br />