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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> y APPLICATION <br /> -� (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby.Made to carry on business in the jurisdictional area of th��noaquin Local He Ith istri t <br /> rn Business Name (DBA) Addresses !�-�Q ��l <br /> aOwner Address <br /> Firm'Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 6 Emergency Telephone No. <br /> Contractor Licence No, �' "'3 3 <br /> LAppiicants Name (Print) 7 Title ST Date 20 <br /> Please check Apolicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) d <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 i <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored I A <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 /> A. K SANITATION PERMIT T/ l) i <br /> Job Address/ cation <br /> y710 -VO' �"�� <br /> Owner Address <br /> 11 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW 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. ❑ PACKAGE TREATMENT PLANT.'-For July 1, -June 30, 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 Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> } <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, a d rules and r ulations he San Joaquin Local Health District. f <br /> h APPLICANT'S SIGNATURE X ' <br /> ,. FOR DEPARTMENT USE ONLY <br /> - '++Fee Is Due: ❑ ANNUALLY ❑-PER UNIT, _ ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLINGREMITTANCE $ REMIT <br /> i BASE EXPLANA ON AMOUNT DUE CHECKED <br />' DATE DATE .. - REMITTED AMOUNT <br /> FEE `7 4 <br /> LESS 1 tv <br /> 1 <br /> II PRORATION `• - f <br /> PLUS € <br /> PENALTY <br /> OTHER } P <br /> OTHER <br /> 7 (5 ao 01>0 16 <br />€ Received by - Date t Receipt No._ Permit No.- Issuance Date Mailed Del' ered - J <br /> APPLICANT—RETURN ALL COPIES Tb: ENVIRONMENTAL HEALTH PERMITISERVICESf 1601 E.HAZELTON AVE.,P.O.Box 2009 ST CKTON,CA 95201 lii <br />