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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> �"uFy <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> _ ENVIRONMENTAL HEALTH PERMIT SEPTAGE ' <br /> _51111__ `� �-f S � LIQUID WASTE 20� !?�rR7'7 <br /> Application is ereb made toica�rryon business in the jurisdictional area of the n Joaquin Local Health District �� <br /> On Business Name {QBA) I�t�[.rt Address—r—'.0, ,moi_ <br /> r' !2 4WAX - <br /> i Owner Address <br /> r <br /> Firm Partners, Addresses and Telephone Numbers p <br /> E Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title 0-4v s Date <br /> Please check Applicable Category (1-7) and f=ill 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.1P I , Color) a �y <br /> Serial No. �) CAL. License No. CAL. Li�se Renewal No. <br /> Capacity Gal.,Weights.&Measures No <br /> Equipment.Parking-Addre`ss <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 LocationkP d i Test Date/Time <br /> 4. 11 SANITATION PERMIT <br /> Job Address/L anon <br /> Own • _Ad"r <br /> SEPTIC TANK ❑ CESSPOOL ACHING FIELD f'' 'SEEP GE P-ITS- L7'IrACKAG#i / l qJ� (!,4Z,.,C1PERMANENT ❑ `TEMPORARY' EW D-REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -J ne 30, 19 '' "°x*" r <br /> Type Construction / DisposalrSite <br /> No. of Units 1 F Equipment Storage/CCleaning Location <br /> {s} <br /> 6. ❑ PACKAGE TREATM£NTEPL"ANT-F6r July 1, -Juner30, 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 Thah41,000 Sq. Ft. <br /> ❑ DRY'CLEANING, Chemicals Used/Amount/Moog <br /> s F ,yp <br /> r I hereby certify that I have prepared this application and that.the work will be done in accordance with San Joaquin County ' <br /> f. <br /> ordinances, state laws, and rules an -reguia - ns of the San�Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> t T <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due-. ❑ ANNUALLY' © PER UNIT 'PER SITE ❑ EACH ❑ January 1 B Received By January 31 ❑ July 1 &Received By July 31 <br /> ;� REMIT <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED } <br /> a AMOUNT <br /> FEE - ..- �y <br /> LESS -- <br /> PRORATION ! <br /> PCUS ,'w E_, i <br /> _PENALTY, <br /> OTHER <br /> OTHER ` kk- <br /> -7 <br /> Received by Date Receipt No, Permit No. Issuance Date Mailed heVKT�Nl <br /> Q" F <br /> `APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL I4EALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P-O-Box 2009 STA 95 r� <br /> _ sQ <br />