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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - � y <br /> r APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> k ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is heTby made arty on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) o w � 'Address <br /> z Owner 0.s— <br /> a `Address <br /> Firm Partners, Addresses and Telephone:Numbers <br /> r a Business Telephone No. ` .J �- Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) G [. 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 /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) I <br /> F � <br /> I Serial No. s t CAL. License No. <br /> f CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> 4 Equipment Parking Address k -, <br /> 2. ❑ PUMPER YARD ' �1 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored _" <br /> ' No. of Chemical Toilets Stored <br /> 3. 11PERCOLATION TEST IL <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. V <br /> Test Location <br /> I Nest Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Loco ion <br /> Owner GJ <br /> Address w <br /> EP TANK ❑ CESSPOOL E,ERIE AC FIELD EEPAGE PIT ❑ PACK E PLA T (A <br /> LUI!rERMANENT ❑ TEMPORARY L�NEW ❑ REPAIR ❑ OTHER 1 <br /> I 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 /> Plant Location # <br /> Plant Capacity <br /> 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. T W <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. $ <br />�. �� by r J #^.�.�:.:%-.T ,K..-...r.. - - �v - .- -•. _ � r. <br /> I hereby certify that I have prepared this applic and'that the work will be done in accordance with San Joaquin County <br /> ordinances, state la7����ns o he'San Joaquin Local Health District: <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT:USE--ON LY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT `— <br /> ❑ PER SITE .❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> .I BILLING I REMITTANCE REMIT <br /> BASE EXPLANATION $ A <br /> DATE DATE REMITTED MOUNT DUE CHECKED <br /> FEE AMOUNT . <br /> LESS <br /> PRORATION < <br /> PLUS <br /> PENALTY p. <br /> OTHER <br /> OTHER <br /> s <br /> -Received-by fz__ Date Receipt No Permit No. Issuance Dale Mailed Dwer <br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 F.HAZELTON AVE.,P.O.Box.2009 STOC ON,CA 95201 <br />