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APPLICATION <br /> — (For Nott-Transferable, Revocable, and Suspendable) - <br /> ENVIRONMENTAL. HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> t'�' -arr � - <br /> j Application.is he� reby made to carryon business in the jurisdictional area of the San Joaquin Local Health District, �u <br /> Address <br /> rBusiness Name (DBA) <br /> z Owner - 'Address <br /> a V Li i ?i� r <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL c tr { Emergency Telephone No. <br /> IL Business Telephone No. .i - } <br /> Contractor Licence No. f <br /> . c. Title - ; Date <br />� L Applicants Name (Print) '-`•-- <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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> IEquipment Parking Address - <br /> 2. ❑.PUMPER YARD <br /> -For July 1, June 30, 19 <br /> No. of Vehicles Stored 4 <br /> a <br /> No. of Chemical Toilets Stored <br /> k 3. ❑ PERCOLATION TEST <br /> f R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> TestLotion Test Date/Time <br /> 4. E SANITATION PERMIT �d <br /> Job Address/Location w_ <br /> ! Address -L.✓�r .' { -.J c,A <br /> Ow er 0 PACKAGE PLANT <br /> L SEPTIC'TANK ❑ CESSPOOL C1L CHING FIELD ❑ SEEPAGE PIT J <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ -OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> I <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 W <br /> Where Certified <br /> Operator Name <br /> A, 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/AM6unt/MO. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin'Counly ' <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> L <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ' ❑ PER UNIT PER SITE ��❑ EACH © January 1 &Received By January July t &Received By July 31 <br /> REMIT <br /> "BASE''•' EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE ;,DATE' REMITTED AMOUNT <br /> FEE <br /> l LESS " <br /> r PRORATION <br /> PLUS a - <br /> PENALTY <br /> OTHER v <br /> OTHER <br /> ,,;- I" <br /> Received by Permit No. Issuance Date" 'Mailed livered <br /> Date Receipt No. r <br /> LLA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/S£RVICESo' - "•, 16(11 E.HAZELTON AVE.,P.O.Bo:20119 - 6TdCKTON, _ <br /> �. -<w..o�i..- ..,v.�:.,.. w... �y��•.- ."�..,- s�� •. •res <br />