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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 /> Oxy ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> On Business Name (DBA) 4e"' At �o -X-4/AC Address 'r <br /> z Owner Address <br /> a I <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ZV;:�4; 9 07 Emergency Telephone No. <br /> Contractor Licence No. �S <br /> Applicants Name (Print). S Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) lJ t <br /> For July 1, June 30, 19 Disposal Sites f <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. i <br /> Capacity Gal., Weights &Measures No. <br /> -r, <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 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test�Locat'on Test Date/Time <br /> 4. SANITATION PERMIT ^ <br /> Job Address/Location %Vz'rC.��v <br /> Owne /¢ !1//E Address <br /> SEPTIC TANK ❑ CESSPOOL 0 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 0 PERMANENT ❑ TEMPORARY ❑ NEW PAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) y <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name Where Certified 'S <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. F <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, r les and ulations of the San aqui Local Health District. <br /> APPLICANT'S SIGNATURE <br /> kFOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT [ZPER SITE - ❑ EACH ❑ January 1 &Received By January 31 _ ❑ July 1 &Received By July 31 <br /> - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT ... <br /> 4 <br /> FEE <br /> LESS <br /> II PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - <br />} <br /> •' Received by Date Receipt No. Permit No. Is uan kale Mailed eliv ed <br /> -. - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 . STO TON,C 8520 <br />