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Applications Will Be Processed When Submitted Properly—Completed.Be Sure To Sign The Application. <br /> r APPLICATION <br /> (For Non-Trans able' Hk cable,and Suspendable) »r! <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> ` Business N me (DBA) Address <br /> Owner arlp a 0 Address n • (7. ��DX r+ -Q C f� �,jrf <br /> 0 Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No. <br /> aContractor Licence No. &rrij 11 <br /> ( L Applicants Name(Print) <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C <br /> 1 <br /> For July 1, June 30, 19 Disposal Sites r <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 /> !F 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> Na. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> ' R.S.or R-.C.E.Name R.S.or R.C.E. No. <br /> i Test Location _ Test Date/Time <br /> t► 4. IWSANITATION PER IT �( - <br /> { Job Address/Location S • 1 �Od � , <br /> JOwner Address + <br /> 19 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ PACKAGE PLANT <br /> JR PERMANENT ❑ TEMPORARY WNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> 1 Plant Location <br /> Plant Capacity L 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 /> a <br /> 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 Joaquin*Local Health District. <br /> APPLICANT'S NATURE X <br /> �s sa <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION _ r <br /> DATE DATE REMITTED AMOUNT DUECHECKED <br /> FEE <br /> LESS <br /> PRORATION /� 6 <br /> PLUS <br /> PENALTY .i W <br /> OTHER <br /> 6 <br /> OTHER - <br /> �5 kO -3301 05$oiv� Ba <br /> Received by- Date I Receipt No. Permit No. lasuance Date Mailed <br /> APPLIcdNr� XIRR 'N eir.cnoiFc Tn. amu—n....�kr., Delivered <br />