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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE Q <br /> 12' 5 =' gv1 LIQUID WASTE <br /> Applicatio isere m e to cif�`on b�+mess in the jurisdictional area of the Joa in Local He th District <br /> HBusiness me (DBA)_`` L �w JG.X�]+4 Add ess � 'fy <br /> 4 Owner�k %(Was Address f <br /> Firm Partners, Addresses and TelNumbers -Z&�e hone Numbers Shad-E 7 y� -34'K-r- <br /> e <br /> � <br /> 4' ` <br /> aBusiness Telephone No. _3�j�- �3 3 Emergency Telephone No. <br /> Contractor Licence No. /ategory <br /> L Applicants Name (Print) l F E Title Date ! Z <br /> Please check Applicable (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. 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 /> No. of Chemical Toilets Stored s <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> t._A <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PER IT <br /> Job Add r s/Location &VkI <br /> c1 <br /> Owner Address 364 <br /> PbEPTIC TANK ❑ CESSPOOL ErLEACHING FIELD MISEEPAGE PIT ❑ PACKAGE PLANT <br /> Ek'PERMANENT ❑ TEMPORARY U-NEW ❑ REPAIR a-OTHER p� 1 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 N <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) Q <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified 1�� <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 pr r this &sth <br /> that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and e �gulan Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X , <br /> FOR DEPARTMENT USE 011 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT 19 PER SITE ❑ EACH ❑ .I 1 &Received By January 31 ElJuly t &Received By July 37 <br /> REMIT <br /> BILLING EM CE $ <br /> EASE E7(PLANATION DATE � E REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> �J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER Qff <br /> tJ <br /> Received by Date Receipt No Permit No. -O 7 e Issuance Date Mailed Deliver <br /> - APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES '9 E.HAZELTON E. .O.%+200 STOC ON,C 95201 <br /> 4 <br /> �� Q <br />