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Applications WIII.Be Processed When Submitted Properly Completed. Be SureToSignTneApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) / SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h eb made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address— ��- 3� '' TG <br /> z <br /> a Address - <br /> Owner <br /> Firm Partners, Addresses and Telephone Numbers <br /> 41, <br /> aBusiness Telephone No. — �''.!r y i F' l _ Emergency Telephone No. <br /> 1 Contractor Licence No. 2q� <br /> LApplicants Name (Print) � � Title:: Date "f <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.. <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 .f <br /> i 3. ❑ PERCOLATION TEST a <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT" <br /> Jo Add`; /,Location <br /> Ovirrier� t7Gtd, Address <br /> SEPTIC TANK. ❑ GESS =---`O , -LEACHING FIELI] ❑ SEEPAGE PIT ❑ PACKAGE PLANT 3 <br /> PERMANENT r -EtmPORAiY�F 1 NEW ❑ REPAIR ❑ OTHER t Iz <br />#. 5. ❑ CHEMI ALITOILETS For July 1,`-June 3Q 19 ; <br /> Disposal.Site <br /> L <br /> w Type Construc a= i <br /> No. of Units EgtiipmentStorage/Cleaning Location(s) �. <br /> 6. ❑ PAGKAGE�TREATMENT PL-ANT For July l,`-June 30;`19 <br /> `F Yem ° .. Where Certified <br /> Operatoe; , <br /> l Plant Location <br /> ` Plant Capaciliy, I" ! 1' No. Units Served <br /> 7. ❑ LAUNDRY For July V -June 30,19 <br /> SIZE: b Less Than 1,000'Sq. Ft., ❑ 'More Than 1,000 Sq. Ft. <br /> i ❑ DRY CLEANING, Chemicals Used/AmounVRo-_' <br /> .� „'� rai,F, y\- � � -moi ,� �'. '3^• � <br /> �. _ ..i <br /> hereby certify that I have prepared'this,application and that the work will.be done.in aqordance with San Joaquin County <br /> ordinances slate-laws, and rules and reg i f the n Joaquin!Local Health-{]istrct <br /> APPLICANT'S SIGNATURE X <br /> FOR-DEPARTMENT USE ONLY <br /> Januar 31' ❑ July 1 a Received By July 31 <br /> Fee Is Due: 11 ANNUALLY El PER UNIT. ❑ PER SITE ❑ EACH 0 janvary-1-&-Receiyyd.by Y', , <br /> 4 REMIT <br /> BASE,„- EXPLANATION_:." BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED � �, '" AMOUNT <br /> i <br /> i t <br /> FEE <br /> s z <br /> LESS w i <br /> PRORATION <br /> PLUS yr ! <br /> PENALTY " <br /> OTHER <br /> �- OTHER •-_ «>r'. y .-a . —_. _� Via- _ <br /> Received by Date _ gReceipt No. Perms[No., Issu nce Date Mailed Delivered _ <br /> j APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES "1601 E:HAZELTON AVE.,P.O:Box 2009 STOCKTDN,CA 95261 <br /> 1 r , <br />