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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> J <br /> APPLICATION <br /> r it (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SEPTAGE <br /> LIQUID WASTE I <br /> Application i hereby made to carry on b siness in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) .` Address C J! S'_ Q�� S' C�Y)71 1/ <br /> a Owner �.�j�/���C� ryL�lG' P�' Address <br /> L) Firm Partners, Addresses and Telep o e Numbers <br /> CL <br /> Business Telephone No. y �+� , <br /> p ..—. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) e �S' Title �d�!' C Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. 13 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites Q? <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 i JJJ <br /> No. of Vehicles Stored �? <br /> i <br /> No. of Chemical Toilets Stored 19 <br /> 3. ❑ PERCOLATION TEST ;I 4 <br /> R.S. or R.C.E.Name I R.S. or R.C.E. No. <br /> Test Location I! Test Date/Time <br /> 4. XSANITATION PERMIT <br /> Job Address/Location CJ p <br /> OwnerAddres <br /> SEPTIC TANK OCESSF: 000 ' EACHING FIELD SEEPAGE PIT PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR r ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 a <br /> Type Construction h Disposal Site <br /> No, of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name II Where Certified <br /> Plant Location II i <br /> Plant Capacity _ No. Units Served i <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 Joa nou y <br /> ordinances, state laws, an ule and regulations of the San Japquin Local Health District. . <br /> APPLICANT'S SIGNATURE X _ <br /> FOR DEPARTMENT USE ONLY <br /> I! r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Ju}y 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE I! EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS ! <br /> PRORATION <br /> PLUS I !; <br /> PENALTY <br /> OTHER l <br /> II <br /> OTHER <br /> Received by - ate Hi Receipt No.' Permit-No.. Issuorlde e Mailed Del v e <br /> APPLICANT—RETURN ALL COPIES ITO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTO ,CA 95201 <br />