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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA)_��fic� ddaX772LlC'rl0� Address <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 7/ Emergency Telephone No. <br /> Contractor Licence No, Ilk <br /> L Applicants Name (Print) Title M Date " 7 g� <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1. -❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> i For July 1, June 30, 19 Disposal Sites ' 1, <br />[ Y I <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 /> r 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> E No. of Vehicles Stored <br /> f No. of Chemical Toilets Stored <br /> r 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. Q\ <br /> t Test Location Test Date/Time <br /> j 4. W SANITATION PERMIT <br /> Job Address/Location ) �� <br /> Owner gay h{ aA7V Address G <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT, Y❑ PAC AGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR + OTH R �1/ l7I�A�Cl�%�� � <br /> 5. CHEMICAL TOILETS For July 1, -June 30, 19 <br /> i <br /> Type Construction Disposal Site f 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 1 <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 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 and regulations of the an oaquin Local Health District, xz <br /> I APPLICANT'S SIGNATURE X i <br /> F <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> r <br /> III LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER # \ <br /> IE' OTHER <br /> Received by Date - Receipt No, Permit No. Issuance Date - Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 S=�OCKTON,CA 95201 - <br />