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" Applications WIII Be Processed When Submitted Properly Completed, Be Sure To Sign The Application.', , <br /> APPLICATION #" <br /> (For Non-Transferable, Revocable, and Suspendable) 1. <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE ' <br /> LIQUID WASTE <br /> Application is ereby made ton bushes in the jur' dictional area of the San Joaquin Local Health Dist r t <br /> H Business Name (DB ) a Q ddre ss�- <br /> Address <br /> a Owner <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. �C � S Emergency Telephone No. <br /> a ( <br /> Contractor Licence No. '? �7),,d`Fifl <br /> Applicants Name (Print) i Title Date_ <br /> Please check Applicable Category ( in the Require Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Disposal Sites - <br /> For July 1, June 30, 19 Dis P <br /> Description(Make/Yr., Color) <br /> • <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity s "`} Gal.,Weights & Measures No.- <br /> Equipment Parking Address # �€ <br /> 2. ❑'PUMPER YARD <br /> For July 1, June'30;'19All <br /> �- <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. O <br /> I� Test L ation <br /> Test t Date/Time t <br /> 4. L SANITATION PERMIT pp r <br /> Job Address/Location <br /> I % Address <br /> Og�-�, PTIC - ' <br /> NK ❑ CESS OL Lf� ACHING FIELD I�EEPAGE PIT .�0rPACKAC,,E•PLANTPERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER ) ' <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal'Site 1 t ttt <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location " - - --- <br /> c ' ► �+ . -s-No.{Units Served— <br /> Plant Plant Capacity r -�,� •E a4 �{J <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 /> r <br /> { <br /> I hereby certify that I have prepared this application and that the work will be done i c r nce with San Joaquin County <br /> ordinances,-state laws, and rule and regulations of the San Joaquin Local Health Distric <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT U ON }1r' <br /> Fee IS Due: ❑ ANNUALLY PER UNIT PER SITE ❑�EACH ❑_ an ry 1 &Received Fly January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMIT CE $ AMOUNT DUE CHECKED <br /> DATE E REMITTED AMOUNT <br /> FEE `-tT A <br /> LESS `J <br /> PRORATION t <br /> PLUS � ,� <br /> PENALTY <br /> OTHER <br /> OTHER ! <br /> r Receivetl by Date Receipt N. Permit No. I l9suance Date Mailed Delivered <br /> t APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTONAYE.,P.O:Boa 2009 STOGKTON,CAT <br /> - <br />