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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 /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br />,,Business Name (DBA) 7,APAP.AISR so A,-,- Address PO lex r µS© <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. `g6p Emergency Telephone No. <br /> Contractor Licence No. 3' <br /> Applicants Name (Print) LJ 062 Z> Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT RECISTRATJON (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 <br /> 3. © PERCOLATION TEST W <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 0 SANITATION PERMIT ' <br /> Job Address/Location g 5 ,tr a..� <br /> Owner t-A Al 0d Address <br /> DO SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 9-SEEPAGE PIT ❑ PACKAGE PLANT <br /> .K PERMANENT ❑ TEMPORARY IM NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,=June 30, 19 t <br /> ( <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location I , <br /> Plant Capacity <br /> No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 191 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> * 1 hereby certify that I have prepared this application and tha the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the n Joaq in Local Health District. j <br /> I <br /> APPLICANT'S SIGNATURE X <br /> r <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1.&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 /> AMOUNT <br /> Lt y ws- ✓ . <br /> FEE ' <br /> .LESS ° <br /> PRORATION <br /> PLUS t <br /> PENALTY <br /> OTHER <br /> OTHER 1 <br /> o <br /> `7 9 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delive d f U I <br /> APPLICANT-RETURN ALL COPIES TO`. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.FIAZELTON AVE.;P.O.Box 2009 STOC TON,C 520 3 ) <br />