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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Applicatlon. <br /> APPLICATION J <br /> (For Non-Transferable, Revocable,and Suspendable) ..� <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> L+Quio wasrE <br /> Applicatio h eby mad to carryon business' the'urisdictional area of the an Joaquin Locallth stri t <br /> Business Name (DBA) Aee Address <br /> z Owner <br /> a Address <br /> Firm Partners, ddresses and Telephone Numbers <br /> aBusiness 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 MEHICLE) . <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) :y <br /> Serial No. CAL. License No. <br /> CAL. LiCc'lse Renewal No. ' <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address = <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 e <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT 4 <br /> Job Address/Location z t---�r1_,0__ .,.- \,�# Vv So <br /> OwnerQ Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ACHING FIELDSEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY 11 NEW ❑ R PAIR ❑ OTHERS ' <br /> 5. ❑ CHEMICAL TOILETS For July 1, -'June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning'Locations) <br /> i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified , 1 <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 /> 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 ul -an reg a ' 'me n Joaquin Health District. <br /> APPLICANT'S SIGNATURE X ° • `�I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY <br /> EJ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July l 8 Received 8y July 31 <br /> BASE EXPLANATION 18iLLING REMITTANCE $ REMIT <br /> _ r DATE DATE REMITTED 'AMOUNT'DUE CHECKED <br /> MOU <br /> * } T <br /> FEE AN <br /> _fT <br /> i Tom. <br /> LESS r <br /> PRORATION 4 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ti -q2 7 <br /> 'Received by - Date Receipt o. Permit Na Issuance Date Mailed <br /> Defive ed <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.HAZELTON AVE.,P.Q,Box 2009 STOC TON,CA 95201 <br />