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A 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 oaquin Local Health District <br /> ,107 Business Name (DBA) 'SGL Address euv ,/ M otb- <br /> z Owner Address <br /> a <br /> U Firm Partners, Addresses and Telephone Numbers <br /> K Business Telephone No. Emergency Telephone No. �- <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title — _/ Date <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 /> 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 M <br /> 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- <br /> Job <br /> ERMIT Job Address/Locati n <br /> Owne � Address "_ <br /> SEPTIC TANK ❑ CESSPOQL TkfACHING FIELD ❑_SEEPAGE PIT ❑ PACKAGE PLANT _ <br /> ❑ PERMANENT ❑.TEMPORARY ❑ NEW F ❑ REPAIR ❑ OTHER - <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _ <br /> Type Construction. '�"'� Dispdsal Site <br /> No, of Units �" Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT""For July 1, -June"30,19 <br /> } <br /> Operator Name~ - Where Certified <br /> Plant Location <br /> Plant Capacity - - '^ _ No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19., — <br /> SIZE: ElLess Than 1,000 Sq..Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. , <br /> r d_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin County <br /> ordinances, state laws, and rule and regu ons-o Local Health District. <br /> APPLICANT'S SIGNATURE X 7j///�/ <br /> I ' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ .10y 1 &Received l3y July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE " ' <br /> r. LESS <br /> '''ORATION <br /> PLUS !„ <br /> PENALTY Y' <br /> OTHER <br /> OTHER <br /> oa <br /> V� <br /> • Received by Date Receipt No. Permit No Issuanc Date I Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK-T,ON;CA 95201 <br />