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Applications Will Be Processed When Submitted Properly Completed. Be Sure To signTheApplication. <br /> APPLICATION <br /> tea; (For Non-Transferable, Revocable, and Suspendabie) SEPTAGE , <br /> ENVIRONMENTAL HEALTH PERMIT . <br /> LIQUID WASTE <br /> Appiicati n is her y made to carry on b�usmess in the jurisdictional area of the San Joaquin Local Health District <br /> �;Business Name (DBA) �3 �A� ! '� ' o.U'S G- Address- <br /> OF <br /> ddress <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers 1 <br /> aBusiness Telephone No. — g�o7 Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> L Applicants Name (Print) <br /> .soNl 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) <br /> For July 1, � June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL LiccRse 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 /> z <br /> No. of Chemical Toilets Stored l <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Location I Test Date/Time <br /> Test <br /> �Lo I <br /> 4. L7 SANITATION PERMIT73v 7©Q� <br /> Job Address/Location <br /> Owner <br /> V E Address �� N' ��� STe <br /> U SEPTIC TANK ❑ CESSPOOL LEACHING FIELD EEPAGE PIT 13 PACKAGE PLANT C, <br /> RrPERMANENT ❑ TEMPORARY �EW ❑ REPAIR ❑ OTHER <br /> I� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �I <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 /> Operator Name Where Certified <br /> Plant Location l <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. it ; <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo, <br /> I'r <br /> I <br /> I hereby certify that I have repared this application.and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a ulesand r ulations f the S Joaquin Local Health District. i <br /> APPLICANT'S SIGNATURE X <br /> y <br /> d <br /> ti S <br /> FOR DEPARTMENT USE ONLY I <br /> Fee Is Due: ❑ ANNUALLY' ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July,31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED I, <br /> BASE EXPLANATION <br /> i DATE DATE REMITTED AMOUNT <br /> FEE <br /> F LESS <br /> PRORATION <br /> PLUS �� <br /> PENALTY <br /> j OTHER <br /> ` OTHER <br /> - hsh6r, <br /> Date Receipt No. Permit No, I uance Date Mailed a lye d ii <br /> Received by <br /> 1601 E.HAZELTON AYE.,P.O.Bo=2009 5T0 TON,CA 201- <br /> APPLICANT—RETURN-ALL COPIES TO: `ENVIRONMENTAL HEALTH PERMITISERVICES - <br />