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Applications Will Be,Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APP�ATI ON <br /> (For Non-Tra s�erable,Revocable, and Suspendable) SEPTAGE f <br /> - - : -.� ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the a Joaquin LSI Health District �Ae } <br /> F Business Name (DBA) Ad ress <br /> ZI <br /> zz Owner <br /> ,sj,IiYy�i� C. C / -,f Address r C� /. <br /> 41 <br /> Firm Partners, Addresses and Telephone Numbers <br /> MEmergency Telephone No. <br /> a Business Telephone No. <br /> Contractor Licence No. ��11 �� Date /��� �� <br /> LApplicants Name (Print)/4t--Ni •" y J Title C� <br /> Please check Applicable Category (1-7) and Fill in the Required Information l— <br /> i 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> t <br /> j Description(Make/Yr., Color) <br /> Serial No. ) CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,,Weights &Measures No. <br /> '1 <br /> Equipment Parking Address I <br /> F 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> f No. of Vehicles Stored <br />{ No. of Chemical Toilets Stored <br /> r' 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT loto p C N — <br /> Job Address/Location <br /> �,V1691/G 0 ro W /O Address cs•` 9 <br /> Owner i ❑ PACKAGE PLANT <br /> I�EPTIC TANK 11 CESSPOOL ❑ LEACHING FIELD EPAGE PIT � <br /> ❑ PERMANENT ❑ TEMPORARY - ' ❑ NEW <LRE�PA ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -tt June 30, 19 C <br /> Type Construction 1 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 I Where Certified � <br /> Plant Location I) <br /> } No. Units Served <br /> Plant Capacity / <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> �. r <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 San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X _- <br /> FOR DEPARTMENT USE ONLY <br /> FFeee: _❑ ANNUALLY ❑ PER UNIT LJ PIR SITE ❑ EACH _ ❑ January 1-&Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> r BASE EXPLANATION DATE DATE REMITTED AMOUNT_ <br /> FEEl� <br /> L LESS <br /> F PRORATION ` <br /> PLUS /890 <br /> PENALTY + <br /> OTHER <br /> OTHER X 7 G� `� *� <br /> i V)O �"L l '50 f <br /> { ate Receipt No, Permit No. Issuance Date Mailed Delivered <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 .STOCKY N,CA 9 01 <br />