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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 /> Application i hereby ma Eto c rry usine s in Slur ictional area of the Sa a uln al Health District <br /> Business Name ( A) 0 1 Address ��.___�-�6 f <br /> z Owner - - _ o <br /> r ddress <br /> D Firm Partners, Addresses and Telephone Num ers <br /> nBusiness Telephone N( Ln/G <br /> Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name(Print) Title Date <br /> Plesse'clieck Applicable Category (1-7)and FIII In the Req red 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. <br /> Capacity Gel.,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 Lpt!etion Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addre-ss/Location �.. <br /> Owner ��^.- �wp� Address '� 9 <br /> 60 ALI- <br /> 13 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ S IT ❑ P CKAGE P ANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW EI-IT 15PA-1R ❑ 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) x 1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location K <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July I,'-June 30, 19 t <br /> . . SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> a , V <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 r f nd regulations �yaa Joaquin Local Health District— <br /> APPLICANTS SIGNATURE X 4��®n <br /> I <br /> y FOR DEPARTMENT USE ONLY ) <br /> Fab Is Due: 13 ANNUALLY 13 PER UNIT ❑ PER SITE ❑ EACH ❑ January i&necelmd By January 31 ❑ July 1 &heceived By July 31 <br /> BILLING REMITTANCE S REMIT <br /> i BASE EXPLANATION DATE AMOUNT DUE CHECKED <br /> DATE REMITTED AMO <br /> FEE � �� pp <br /> LESS W <br /> l PRORATION " <br /> PLUS <br /> PENALTY - - <br /> OTHER " '• .�"x ... <br /> FIJ <br /> OTHER III <br /> ece vedD� Date IiacNpt No. PWMII NO. �/�—C1/�, <br /> /-'uhncq Dare _Meted Delivered <br /> APPLICANT—RETURN ALL COPIES To- FNVWnYaaYliu ueu�u eeeuoueemw.. _ _ <br />