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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 9- APPLICATION - <br /> Ar Non-Transferable, Revocable,and Suspendable) . <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> rApplication is reb madam carryon business in the jurisdictional area of the$aq Joaquin Local Health District <br /> F Business Name (DESA) Address—,✓9� )_ � � /►�ITC/ � __ <br /> 4 Owner t—U C;:-45 2 Address NZ le- <br /> 7u <br /> e7u Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. s <br /> Contractor Licence No. v� 7 <br /> L Applicants Name (Print) - Title C�F7— w 3 ��— Date —1 <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 o <br /> Description(Make/Yr., Color) <br /> Serial No. _ CAL. License No. CAL. License Renewal No. <br /> Capacity _ fir Gal., Weights 8 M2asures <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.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 1—orn/L <br /> Owne — r' ^-� Address R A -57ATe <br /> W11EPTIC TANK ❑ CESSPOOL ACHING FIELD © SSEE SAGE PIT IJPACKAGE-PLANT 74C�s <br /> ❑ PERMANENT ❑ TEMPORARY <br /> 1:1 NEW EPAIR ❑ OTHER , <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 1 . <br /> Type Construction Disposal Site LLQ.• <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 fl k <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. ^� T <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 Yules and re ations f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ; <br /> C 'GV <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY PER UNIT PER SITE ❑ EACH-0. January-1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> "� AMOUNT <br /> {�.. <br /> FEE 100 <br /> LESS <br /> PRORATION <br /> PLUS <br /> r <br /> PENALTY <br /> _ —OTHER <br /> OTHER <br /> Received by DateeceptNoPermit No t Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCXTON,CA 95201 r�' <br />