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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Afq.-_. <br /> APPLICATION <br /> (Fo�on-Transferable, Revocable,and Suspendable) %now ✓I S SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT �� <br /> LIQUID WASTE <br /> Application i hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address <br /> Owner Addresses `1 <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. /e j Emergency Telephone No. <br /> Contractor Licence No. 2g ZZ Ilro N <br /> Title Date �'��'�� 0— <br /> Applicants Name (Print) Q' <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 /> CAL. License No. CAL. License Renewal No. <br /> Serial 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. No. <br /> R.S.or R.C.E. Name <br /> Test Lge'ation Test Date/Time <br /> 4., SANITATION PERMI <br /> 11�i1�/✓, G� <br /> Job Address/Location �J 7 / pct- <br /> Owner 1df 92Q Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ®-SEEPAGE PIT F KAGE PLANT or <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ®REPAIR 11 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Locafon(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July-1,-June 30, 19 -� s�� _ -C <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 pnd regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE Af 1 <br /> Fee IS Due: ANNUALLY PER UNIT PER SITE ❑ EACH ❑ Jan y 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> I BILLING REMIT NCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE ATE REMITTED AMOUNT <br /> 0 <br /> FEE 7 —_ <br /> LESS ---'- -- -- -- -'-- <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date <br /> Receipt No. Permit 0:3,No. Issuance ate � Mailed eliver <br /> 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOC ON,CA 520 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL H ALTFJ PERMIT/SER,V(}�� <br /> G� jlJ` <br />