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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) — ,1 <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE l <br /> LIQUID WASTE �. <br /> Appl ication ' ereby mad to c rry o bus ess in he jurisdictional area of the San Joaquin Local Health Oistrlc <br /> rn Business Name (D IT 7 <br /> A) `- n Address �� 7� 7r��':` <br /> z Owner Addresses -e— <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ���- �� �'-r Emergency Telephone No. <br /> Contractor Licence No. �z <br /> LApplicantsNamill—e (Print) '� 9. Title /`��-d• Date <br /> Please check Applicable Cbtegory (1-7) and FIII in the equired Information <br /> 1. ❑�P,UMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Fo'�Ju1, "'t`t `June 3019 Disposal Sites 7 �, <br /> i <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Renewal Na. <br /> Capacity Gal., Weights & Measures Na. <br /> r .siW <br /> Equipment Park Ygg_AddresTs _ _ _ <br /> 2. ❑ PUMPER YARD s <br /> For July 1, I June 30, 19 <br /> No. of Vehicles'Storeed _ 1 '67ar <br /> No. of Chemical Toilets Storedl � <br /> 3. ❑ PERCOLATION TEST � ► 4 I e <br /> R.S. or R.C.E. Name I R.S. or R.C.E. No. <br /> Testi L ation 4 I ( Test Date/Time <br /> 4. 117 SANITA710N PERVIT <br /> 57 2r �y r `YT' 1� ad' X <br /> Job Address" tion e1 GC.t <br /> Owner `� AddressV EPT_lC TANK ❑ CESSPOOL s L CHING FIELD EEPAGE PIT ❑ ACKAGE PLANTERMANENIf ❑ TEMPORARY NEW 1 ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS Lor July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of UnitsEquipment,Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE TREATMENT PLANT For ruly 1, -June 30, 19 i <br /> Operator Name }' Where Certified <br /> Plant L cation <br /> Plant Capacity __;-No. Units Served_ <br /> 7. ❑ LAUNDR.Y For July 1, -June 30, 19 -- <br /> SIZE:-_'�J❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ) <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 rule d regulations of the San Joaquin Local Health District. i <br /> APPLICANT'S StIGNATURE X ' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY _ ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT r <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT L <br /> FEE � I t <br /> LESS. <br /> PRORATION <br /> PENALTY <br /> OTHER <br /> OTHER <br /> — 9/1-7/ <br /> i <br /> Received by Date Receipt No ernnit No. Issuance ate Mailed Delivhd .APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES1601.E.HAZELTON AVE.,P.O.Box 2004 STOC45201 �? -. <br />