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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transterable,`Wvvocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE. <br /> LIQUID WASTE <br /> Application is hereby made to Carry onbusiness in the jurisdictional area of the / J uin Local H I District. <br /> v;Business Name (DBA)/"I�A'/ T�Cff �/l�� __.�© Address " x ��rvA _S1 _��/ �J 6 <br /> a Owner Z J/7/�� � f Address�G' ZIJVC�✓ �� vTit 72: . C �Jr•� 1'� <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. ZCl p- — -2V2Emergency Telephone No. <br /> Contractor Licence No. ca <br /> LApplicants Name (Print) F 4 -< Title Q 6� Date Z Z6 <br /> Please check Applicable Category (1-7) and Fill in the Required Information 1 <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 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. Q SANITATION PERMIT A_r <br /> Job Address/Location <br /> Owner Address <br /> :�PTIC TANK ❑ CESSPOOL ACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT j <br /> PERMANENT ❑ TEMPORARY L7 NEW ❑ REPAIR ❑ OTHER IN <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 )) D <br /> T I (. C U 2s� 'An," Disposal Site �. �6 <br /> Type Construction <br /> No. of Units _'z Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name Where Certified <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 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 Jo uincal Hea Di <br /> APPLICANT'S SIGNATUREX <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 13 ANNUALLY C1 PER UNIT u PER SITE 1:1 EACH El January 1 &Received By January 31 ElJufiy I &Received By July 31 <br /> REMIT }+d <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER T <br /> w - <br /> OTHER , <br /> 7 <br /> Re eived by Date Receipt No. Permit No. Issuance Date Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,Y2O1 <br />