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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i ereby made carry on business in theeluris Ictional area of the San Joaquin Local Health District <br /> F <br /> Business Name (D )_ 2, �� Address �� � �� 7:Z _ <br /> aOwner �f� _ _ Address ✓� --� �`�__ <br /> Firm Partners. Addresses and Telephone Numbers -- <br /> aBusiness Telephone No. 3� s� �s _ Emergency Telephone No. <br /> Contractor Licence No. <br /> a <br /> Applicants Name (Print) Title Date 7-91 <br /> Please check Applicable Category (1-7) and Fill in the Required Information -� <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�Lation Test Date/Time— <br /> 4. Lid SANITATION PERMIT <br /> Job Address/Location <br /> Ow9er .�'�"`� �'`�'�-" �i Address 4/O <br /> �PTIC TANK ❑ CESSPOOL [ ACHING FIELD T ❑ PACKAGE PLANT <br /> PERMANENT <br /> ] TEMPORARY NEW ❑ REPAIR IJ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction _ Disposal Site _ _No. of Units Equipment Storage/Cleaning Location(s) - — <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> fff SIZE Cl Less Than 1.000 Sq. Ft-, El More Than 1,000 Sq. Ft. <br /> I ❑ 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 rule and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X -- r <br /> FOR DEPARTMENT USE ONLY <br /> ❑ ❑ ❑ <br /> El January 1 &Received By January 31 ❑ Suly 1 8 Received EBylJury 3? <br /> Fee Is Due: ANNUALLY PER UNIT PER SITE <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE J <br /> i LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ' OTHER n <br /> I OTHER <br /> I <br /> Date Receipt No. Permit No. I ante ate Mailed Delivered <br /> Received by a... .,.tee,+...,ave o n A, >nna CTOCKTON.CA 95201 <br />