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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. i <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> T F ENVIRONMENTAL HEALTH PERMIT s <br /> LIQUID WASTE . <br /> Application i ereby made to car on business in the jur' dictional area of the San Joaquin Local Health D�i�s�tr�ic/t <br /> Address��+ '7/_ 2 _1 <br /> r Business�NamrneBA) Address <br /> zOwner <br /> J Firm Partners, dresses and Telephone Numbe <br /> aBusiness Telephone No. ,-13 Emergency Telephone No. i <br /> It Contractor Licence No. Z� <br /> Title Date �`4-2 <br /> Applicants Name (Print) Q <br /> PI'ease check�Applicable Category(1-7)'and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ` <br /> *" "' '"' ., Disposal Sites <br /> y <br /> For July 1, June 30, 19 11-1 <br />, VDescription.(Make/Yr:LColor) CAL. License Renewal No. <br /> Serial No., z CAL. License No. ,i <br /> Gal.,Weights &Measures No. <br /> Capacityy ��. .. * ! <br /> Equipment Parking`Address <br /> I. <br /> 2. ❑ PUMPER YARD; <br /> For July 1,,« June 30, 19 <br /> No. of Vehkcles Stored 4L ) <br /> No. of Chemical Toilets Stored '+ ' <br /> 3. [:1PERCOLATION TEST'~` <br /> • . -�• R.S.or R.C.E.No. <br /> R.S.or R. E. Name # . <br /> Test L ation�T 1 ! Test Date/Time • __ <br /> 4. SANITATION PERMIT <br /> Job Address/"cation U Z.. 4 - i , <br /> Ow 'F Address _ <br /> L7EPTiC K` ❑ CESSPOOL �' EACHING FIELD �BT'AGE PIT 13 PACKAGE PLANT D <br /> fiJ PERMANENT ❑ TEMPORARY zi� +NEW (� EP.AIR,,_, „�❑ OTHER f .0 <br /> 5. 11 CHEMICAL TOILETS For July 1, 1tJune 34, 19 i <br /> _ Type Construction ;I Disposal Site + <br /> No. of Units Equipment Storage/Cleaning Location(s) f E <br /> ti <br /> fi. ❑ PACKAGE TREATMENT PLANT For July 1, -June 3D, 19 • i r i <br /> �'. �i4... � • Where Certified j <br /> Operator Name 1 : e <br /> Plant Location — --.- <br /> i Plant Capacity No. Units Served A <br /> k 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> II SIZE: ❑ Less Than 1,040 Sq. Ft., ❑ More Than 1,004 Sq. Ft. , <br /> r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f <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 rules and regulations of the San Joaquin Local Health District, <br /> k APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: [I ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH s ❑ January l 8,Received By January 31 C] July 1 &Received REBy MIT 31 <br /> r <br /> j f BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - -P <br /> I OTHER <br /> 4 OTHER 3 <br /> fPermf' Is a e D to Mailed Delivered <br /> Received by Date t Receipt No- it No. <br /> 1601 E.HAZEL AVE.,P.O.Box 2009 STOCK70N,CA 95201 <br /> APPLICANT--RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> � <br />