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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 9. <br /> rte. APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hLereby made to carry on business in the risdiq,tional area of the San Joaquin Local Health District <br /> r imsiness Name (DBA) �� <br /> Address767 <br /> � <br /> <Owner � ddress <br /> 9 Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. fl S O s Emergency Telephone No.ft. } <br /> Contractor Licence No. 07 `L'`' — 10-16_717 } <br /> Applicants Name (Print) �� Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> I � <br /> For July 1.1' June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL-License No. __ CAL.Lice-ise 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 oc+ <br /> -a. <br /> f 3. ❑ PERCOLATION TEST <br /> No. <br /> or R.C.E. — <br /> 1 R.S.or R.C.E.Name R.S. <br /> } Test Location Test Date/Time <br /> 4. 61 SANITATION PERMIT <br /> Job Address4Location�q 9 <br /> Owner. Address - <br /> �p� ❑ PAC GE PLANT g�� <br /> La SEPTiG TANK 13 CESSPOOL �EACHiNG FIELD IT <br /> ❑ PERMANENT 13TEMPORARY Ua NEW ❑ REPAIR 11 OTHER <br /> I ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> _ pe Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> S S. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> I Operator Name '- —Where Certified <br /> i Plant Location .. <br /> ( No.Units Served <br /> Plant Capacity <br /> 7. 0 LAUNDRY For July 1. -June 30. 19 <br /> SIZES ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,(100 Sq. Ft. <br /> I ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> i <br /> Y I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> 1 ordinances,state laws,,and rules and egulations of the n Joaquin Local Health District. <br /> F ..Q.. <br /> APPLICANT'S SIGNATURE X <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> i Fee Is Due:D ANNUALLY ❑ PER UNIT PER SITE ❑ EACH 0 January 1 &Received By January 31 ❑ July 1&Recew dBy July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> ' ♦fes v <br /> FEE' v! y <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> t`. OTHER <br /> 1 OTHER <br /> - Received Oy Date - <br /> Receipt No erm t No sssuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERUtTISERVICES -tb0t E.HAZELTON AVE.,.P. Box ZO_ / TON,CA i'2Ot <br />