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r 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 hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> mBusiness Name (DBA) Address <br /> z Owner S- Address 7'f�.� C_�i9�i}/�/ dc• -sjJ�'y <br /> r <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> �Applicants Name (Print) e5 a/� Title —��`w� Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information } <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �f <br /> For July a, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License 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 /> 0 <br /> No. of Chemical Toilets Stored V <br /> 3. ❑ PERCOLATION TEST j <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test bate/Time \14 <br /> 4. Lk SANITATION PERMIT <br /> Job Address/LocationOD7 ' 7 <br /> Ow r M t.S Address �.L �! —� <br /> Ow <br /> TANK El CESSPOOL LEACHING FIELD B SEEPAGE PIT 11 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> J <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 <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 Joaq in County <br /> ordinances, state laws, and uI and regulations of the San Joaquin Local Health District. } <br /> APPLICANT'S SIGNATURE X <br /> v <br /> 213 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received Tianuary 31 ❑ July 1 &Received By July 31 J <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE d Yt' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER " <br /> OTHER <br /> iERj 519 U bC <br /> 3;), �J <br /> Received by D to I Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. ST�CKT =rR�5201 , <br />