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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> r LIQUIf1 WASTE ► C <br /> Application . ereby mao to carry o business in the juri dictional area of theJoagquui"n�Local Health District <br /> Sa t S <br /> I Business Name BA)- �:a "tC' Address �1�^-�7 7 <br /> aOwner AI LOT Address _ <br /> J Firm Partners, Addresses and Telephone Num rs <br /> aBusiness Telephone No. _3l —s Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title 44 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 L <br /> Description(Make/Yr., Color) ._ <br /> c <br /> Serial No. CAL. License No. CAL. Licc,se 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 ` <br /> R.S. or R.C.E.Name R.S. or R.C.E. No. <br /> t Test Location Test Date/Time <br /> I 4. ❑ SANITATION PERMIT <br /> Job Address/Location / s�/� ' �- \ <br /> t 'TIC TANK ❑ CESSPOOL �L'EACHING FIELD SEEPAGE PIT PACKAGE PLANT <br /> Cl/PERMANENT ❑ TEMPORARY 117 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 I 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 /> i <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, and rule5,aob regulations of the J aquin Local Health District. <br /> c <br /> APPLICANT'S SIGNATURE X <br /> } <br /> a <br /> e 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 /> } BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. hPermit No I suance Date Mailed Delivered -fU <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PE MIT/SER ICES 1661 E.HAZELTON AVE.,P.O.Boz 2009- STOCKTO CA 95201 <br /> _ <br />