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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Siqn The Application. <br /> APPLICATION <br /> r Non-Transferable, Revocable, and Suspendabl,_ <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio is eherbade to car n b ss i e jurisdictional area of the'an oequin�ocaI HeAlth District <br /> r Business Name ( BA) Address ''TT 1 j�j p4 z �7 eft <br /> aOwner A dress 1*C'410 4t'na- <br /> J Firm Partners, Addresses and Telephone umbers A a�_e <br /> a. Business Telephone No. -A;& <br /> g $` Emergency Telephone No. _ <br /> Contractor Licence No. /13 t__& <br /> L Applicants Name (Print)___- - - - Title • Date 74 <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._ of <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD (Y <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 ---- .0 <br /> 4. �Q SANITATION PERMIT <br /> Job Address/Location `"—r <br /> Owner Address <br /> /J 1A1/�� _ Address -- <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING 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 /> 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, and rules an regulations of the Sa Joaquin o I He Ith istrict. <br /> APPLICANT'S SIGNATURE X -a) , --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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE -' <br /> LESS d <br /> PRORATION -- --- <br /> PLUS <br /> PENALTY _- <br /> OTHER <br /> OTHER NNN <br /> O 1 t ,o <br /> Received by ate Receipt No. ermit o. Issuance Dae Mailed eliv ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO TON,CA 95 01 1671ll <br />