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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 /> I ' ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District /1 <br /> wBusiness N —JL1ame (DBA),_ g in Address . �• <br /> aOwner l 1111.,41 al G „ /-. .wT Address ' <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 420 lltZ ^` Emergency Telephone No. <br /> Contractor Licence No. VICA I <br /> L Applicants Name (Print) _ )WTitle — t" 0— Date <br /> ;i. <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMITREGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 ��� Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, SMI CAL. License No. CAL. License Renewal No. <br /> Capacity Ill Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 �' r <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 II. Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/, ocation � I AI �I 71 m Col. �! _ <br /> Owner gyp, Address q �/ <br /> LT SEPTIC TANK ❑ CESSPOOL a-fEACHING FIELD © SEEPAGE PIT ❑ PACKAGE PLANT i <br /> ® RMANENT 11TEMPORARY Yd NEW ❑ REPAIR © OTHER <br /> "E <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units �� Equipment Storage/Cleaning Location(s) a3 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> a <br /> Plant Capacity !II No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -Juba 30, 19 <br /> SIZE: Less Than 1,000 Sq. Ft:, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Use id/Amount/Mo. � <br /> II i <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 Joaqu' Local He Ith District. <br /> APPLICANT'S SIGNATURE X <br /> I�. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY )11 PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July I &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE �� EXPLANATION - DATE DATE REMITTED AMOUNT DUE CHECKED <br /> I�I AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS `I <br /> -PENALTYIL <br /> OTHER I`ll <br /> OTHER pel 0Received by Da Receipt No. Permit No. Issuance Date Mailed APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE$ '1601-E.HAZELTONAME.;P.O.Box 2009- <br /> II� <br />