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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> APPLICATION '\j <br /> ! (For Non-Transferable, Revocable, and Suspendable) <br /> 1. <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE V <br /> ! Application is hereby ma a to carry on business in the <br /> r' diction area of the Sanoaquin Local eat District f� <br /> I Address v C� <br /> Business Name DBA) <br /> aOwner Address <br /> Q Firm Partners, Addresses and Telephone Num ers <br /> CL <br /> Business Telephone No. .5 �d`S✓ Emergency Telephone No. <br /> C <br /> Contractor Licence No. �! r �— —] r <br /> LApplicants Name (Print) Title Date <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 /> SCAL. Licc Ise Renewal No. <br /> Serial No. CAL. License No. <br /> t 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 /> f 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 <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location �� 9 <br /> Oly4er Address C <br /> PTIC TANK ❑ CESSPOOL L CHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> L�-PERMANENT ❑ TEMPORARY EW ❑ 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. 13 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 _ <br /> Operator Name } Where Certified <br /> Plant Location <br /> Plant Capacity No. Un is Served <br /> r 7. ❑ LAUNDRY For July 1, -June 30, 19 %451 _ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than..IOO Sq:`.Ft. 1-4f.4 <br /> C3 DRY CLEANING, Chemicals Used/Amount/MoN_ t. <br /> 4 <br /> t * • <br /> I <br /> I hereby certify that l have prepared this application and tha_t_the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules d regulations of tfie San�rJ quin;:L�oocal_;HH allth District. <br /> APPLICANT'S SIGNATURE X <br /> a <br /> FOR'DEPAfRTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT jXPER 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 /> :l DATE DATE REMITTED AMOUNT <br /> FEE <br /> I LESS I' <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> —Q 9A <br /> G er Received by .—,�.. Date - Receipt No. Permit Na Issuance Date Mailed D liv _ I L fV <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON,AVE.,P.D.Box 2009 ' STOC >CA 9520. _ <br />