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� APPLICATION <br /> + (For W—Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application,ii5 her by Pdetocarrylppbusines in the jurisdictional area of the Sa` aqui ocal Health District <br /> ness iNxkie {DBA} ���— Address <br /> erAddress 40. C <br /> Partners, Addresses and Telephone Numbers— <br /> ness Telephone No. �'-3f.3_3 Emergency Telephone No. <br /> Tactor Licence No. '7X/ <br /> icants Name (Print) i 4: plc- Title Q Jk Date <br /> se check Applicable Category (1-7) and Fill in the Required Information <br /> 1 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> July 1, June 30, 19 Disposal Sites <br />:ription(Make/Yr., Color) <br /> al No. CAL. License No. CAL. Liccnse P,enowal No. <br /> acity Gal.,Weights & Measures No. <br /> ipment Parking Address <br />-1 PUMPER YARD <br /> July 1, June 30, 19 <br /> of Vehicles Stored <br /> of Chemical Toilets Stored <br /> PERCOLATION TEST �. <br /> or R.C.E. Name R.S. or R.C.E. No. <br /> L cation Test Date/Time c, <br /> SANITATION PERMIT <br /> AddresqLLocation <br /> ler Ad Tess ❑ PACKAGE PLANT <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD �EPAGE PIT <br /> PERMANENT ❑ TEMPORARY LJ-NEW ❑ REPAIR ❑ OTHER <br />:3 CHEMICAL TOILETS For July 1,-June 30, 19 <br /> e Construction Disposal Site <br /> ct Units Equipment Storage/Cleaning Location(s) <br />❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> gator Name Where Certified <br /> It Location <br /> tit Capacity No. Units Served <br /> tD LAUNDRY For July 1, -June 30,19 <br />{ : ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I <br />)RY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I.have prepared this apWMation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an s d regula f t San Joaquin Local Health District. <br />'LICANT'S SIGNATURE 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 /> BILLING REMITTANCE $ ZINT <br /> T <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE ED <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCJQTON,.CA 95201 r I <br />