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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> f APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> i LIQUID WASTE <br /> Application i ereb�r made to carryon bus Hess in the juris ctional area of the Sa Joa In Local Health Distf t (j' <br /> H Business Name (DSA) - Address A 76 ? �' <br /> r L <br /> Z Owner <br /> y 4 <br /> 4 Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. +0.S~ Emergency Telephone No. <br /> Contractor Licence No. �� a <br /> I L Applicants Name (Print) <br /> Title Date. �� <br /> Please check Applicable Ca#,gory {1-7) and�Fillin �Requ iedlnfo�rmation t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, i _ June 30, 19 Disposal f <br /> _�-•"._ �, � posal Sites <br /> Description(Malt,/Yr., Color) <br /> f <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time J <br /> 4. A SANITATION PERMIT <br /> Job Address/Loa ion l <br /> OwnerAddr,.ss�.� dd. <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIE'LPAGE PIT' PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER' v^j <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 It Where Certified # <br /> Plant Location I <br /> Plant Capacity I No. Units Served € i <br /> 7, ❑ LAUNDRY For July 1, -June 30, 19 tl r <br /> SIZE: ❑ Less Than 1,000 Sq. Ft-; ❑ More Than 1,000 Sq. Ft. q <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. f +` <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 rules a-ad regulations ofthe Jo quin Local Health District. <br /> I <br /> APPLICANT'S SIGNATURE X <br /> " FOR DEPARTMENT USE ONLY y „i <br /> Fee Is Due: ❑.ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1.&Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT , <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER } <br /> itlr <br /> �'. <br /> Received by Date R -79--1ceceipt No. Permit No. Issuance Date Wiwi DelL <br /> ered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTD 9 1 <br />