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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 here�y ad ofJ ry on business in the jurisdictional area of the San Joaquin Lo Hea th District <br /> ,�Business Name (DBA)� n /Tj �(��y� AddressX ��� <br /> aOwner�/1/lr/R'� .i' Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name {Print) Title 49ii.4.r ei�_ Date 9 <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 /> } <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address � t. <br /> 2. ❑ PUMPER YARD <br /> 4�*17 <br /> For July'l, June•30M,9 <br /> No. o icles Store <br /> No. of Chemical Toilets Stored <br /> 1 3. ❑ PERCOL'ATION TEST <br /> R.S. oj R E. Name R.S. or R.C.E. No. <br /> Test L'bc tion A; <br /> �" # Test Date/Time <br /> 4'S NITATION PERMIT .-1 <br /> Job+ dress/Locati O <br /> Owne 1. 4 C'�� Address <br /> PE T ---�O-GE$SP OLLE D :&S'EEPAGEEIT ❑ PACKAGE PLANT T� <br /> ERMANENT ❑ TEMPORARY ff NEW REPAIR El OTHER <br /> 5. ITCHEMICAL TOILETS For July 1, -June 30, 19 <br /> tictlt..,a '1 <br /> Type onstrun9. Disposal Site s- N <br /> No. o nits _..a Equipment Storage/Cleaning Locations) '^ <br /> 61 ❑ P&t� AG"LITREATMENT PLANT For July 1, -J nue 0, 19 <br /> s9Wjrator"iMe��� Where Certified <br /> Plar(t Lotion <br /> Plant, ,opacity No Units Served <br /> 7. ❑ AUNDRY For July 1, -June 30, 19 <br /> SIZE: 'ess TFtan 1,000 Sq. Ft., ❑ More Than 1,00 Sq. Ft. <br /> _-Z . ! <br /> 11DRY LEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this applica,ion a d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulation t an'Joaquin Local Health District. <br /> r # <br /> APPLIC NT'S SIGNATURE J* <br /> FOR DEPARTMENT USLY <br /> Fee Is Due: 11ANNUALLY ❑ PER UNIT WPER SITE 31100 EACH ❑ u y 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BIDING fTTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT pUE CHECKED E ATE REMITTED AMOUNT <br /> D <br /> 99 <br /> FEE 1 <br /> LESS <br /> PRORATION <br /> PLUS _ - <br /> PENALTY— <br /> OTHER �� # <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Deliv red q <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.ao■2009 STO KTON A 95241 <br />