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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 /> Applicati is hereby made to carLy on business in t e jurisdictional area of the San Jo gLin Local Hea District <br /> Business Nam (DBA) { � Address7�7 <br /> a Owner l Address ' 7 ) <br /> ,1 <br /> Firm Partners, Addresses and Telephone Numbers <br /> 0.a Business Telephone No. 3.19' (-7©� Emergency Telephone No. <br /> Contractor Licence No. Z.2 <br /> L Applicants Name (Print) r= Ir 4-0d 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) r <br /> Serial No. 1' CAL. License No. CAL. Licc,se Renewal No. <br /> 'F <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address �) <br /> 2. 11 PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST r <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location q Test Date/Time <br /> SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address )V #4 8 152 3 7�' <br /> SEPTIC TANK all CESSPOOL ACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> GI(PERMANENT ❑ TEMPORARY LJ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 <br /> r <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: ❑ 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 ruI s and regulations o the San Joaquin Local Health District. <br /> II <br /> APPLICANT'S SIGNATURE X <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEES <br /> LESS r� <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER _ - <br /> e <br /> Received by Date Receipt No. . Permit No -- Iss(uancb Date Mailed D livere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES n 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK. N,CA 85201 7 `� <br />