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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (ton-Transferable,Revocable,and Suspendabls <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appl ication is.herey mad carw on business in the jurisdictional area of the San Jo In Lp I Hes Distir ^ �} <br /> Business Name (DBA) 1'S'u YDO �� Address [�- 04 <br /> Owner -I o 0 /' s=;& 5-- .A "J <br /> Firm Partners,Addresses and I p one Numbers <br /> Business Telephone No. — -!Z- A-6^ I (P Emergency Telephone No. <br /> Contractor Licence No. C <br /> Applicants Name (Print)__bo,L L.J-e-\ [ ('.- Title �M kk 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) <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 Q <br /> No.of Vehicles Stored r III, <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 1 <br /> R.S.or R.C.E. Name R.S.or R.C.E.No. <br /> Test cation Test Date/Time <br /> 9. SANITATION PERMIT <br /> Job Address/Loc <br /> tion <br /> w�" IE <br /> OEa� <br /> Se;n Address s- r <br /> ES TICTANK ❑ CESPOOL apE ING FIELD EEPAGE PIT ❑ PACKAGE PLA11T <br /> L-rPERMANENT ❑ TEMPORARY ED�NEW <br /> G / n <br /> ❑ REPAIR/gyp ❑ OTHER ,Vew <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site _ <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified W <br /> Plant Location <br /> Plant Capacity 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 /> 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,an ules and regulations oil the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X C•/�/ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PEN SITE ❑ EACH ❑ January 1 9 Received By January 3/ I7 July 1 6 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> <s YS <br /> LESS <br /> PRORATION <br /> PLUS - " <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 06060 .� <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed I Delme <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.H ELTON AVE,P.O.Box 2009 STOC O Ot <br />