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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 /> I Application is hereby made to carry on business in the jurisdictional area of th San Joaquin Local Health District �3 <br /> ,Business Name Address � Z� �� .5-MCL - -yze'-j-- --- <br /> Owner Address <br /> irm Partners, Addresses and Telephone Numbers <br /> i Business Telephone No. +`I � '"" Emergency Telephone No. <br /> Contractor Licence No. <br /> F\pplicants Name (Print) IST—+ 0= SIUS Title 5_jAAATC+ .— Date I Q' f <br /> )lease check Applicable Category(1-7) and Fill in the Required Information <br /> 1, © PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> F]or July 1, June 30, 19 Disposal Sites <br /> ascription(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL, License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> FEquipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July1, June 30, 19 <br /> -No. of Vehicles Stored <br /> o. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> S. or R.G.E. Name R.S. or R.C.E. No. <br /> es,t�,Loc tion Test Date/Time i <br /> 4, tI SANITATION PERMIT <br /> Job Address/Location <br /> [Owner - "-' ddress 'S } d <br /> ❑ SEPTIC TANK ❑•CESSPOOL ❑ACHING FIELD C- SEEPAGE PIT ❑ PACKAGE PLANT -� <br /> 0 PERMANENT ❑ TEMPORARY ❑ NEW a-'REPAIR © OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19- <br /> T ype <br /> 0, 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 /> F'Operator Name Where Certified <br /> Plant Location <br /> r. <br /> Plani Capacity No. Units Served <br /> R <br /> ❑ LAUNDRY For July 1,-June 30, 19 <br /> IZE: . ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> i <br /> l I hereby certify that I h e prepared this applicati d that t e ork will be done in accordance with San Joaquin County <br /> ordinances, state laws, d uses and_r ulations of a an Joa n Local Health District. <br /> APPLICANT'S SIGNATURE <br /> 04 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received R-"G ry 1 - ❑ July 1 &R eived ByJuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ < AMOUNTDUE CHECKED DATE REMT77ED , a AMOUNT <br /> FEE Z f T' .. <br /> LESS <br /> PRORATION <br /> PLUS O <br /> PENALTY <br /> OTHER ' <br /> ` OTHER <br /> Received by Date Receipt No. Permit No. nuance Date Mailedeliver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOC ON,CA Rat <br />