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Appiidations Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Y APPLICATION I <br /> (For Nbn-Transferable;Revle,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE Ci 0 <br /> Application is reby made to carry on business in the jurisdictional area of the San-Joaquin Local Health District } , <br /> rn Business Name {DBA) e` Address ' �"f 7E -7 + <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. _:�, sr s Emergency Telephone No. <br /> J <br /> Contractor Licence No. 2- 2 Applicants Name (Print, Title Date /-;7- <br /> Please check Applicable Category (1-7)and Fill in the Requir416 Information <br /> f 1. El PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I � <br /> i For July 1, June 30, 19 Disposal Sites 9 <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 p - <br /> *-No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 7 0 <br /> R.S.ZorR .E. Name � R.S. or R.C.E. No. W' <br /> ion Test Date/Time �s _ITATION PERMIT `'` <br /> Job Address/Lo ation 3 '� <br /> i f��� <br /> O er f`«�+ - i Address <br /> WLTJ SEPTIC TANK ❑ CESSP L LEACHING FIELD ❑1EEPAGE PIT ❑ PACKAGE PLAN <br /> 11 PERMANENT ❑ TEMPORARY :❑ NEW EPAIR �IV,'- ❑ OTHER <br /> I 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _.. <br /> Type Construction Disposal Site"" " " <br /> y'No. of Units Equipment Storage/Cleaning'Location(s) f <br /> 6�❑'PACKAGE TREATMENT PLANT For July 1, -June 30, 19 -w-- <br /> Operator Name Where Certified 4 <br /> Plant Location <br /> Plant Capacity No. Units Served t <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 <br /> a <br /> I hereby certify that I have prepared this application and that the work will be done in accordance viitli San Joaquin County <br /> ordinances, state laws, and rule d regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ... C <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jan ry 1 &ReceivedByJanuary 31 ❑ July 1 &Received By July 31 <br /> REMIT- <br /> BASE REM ANCE $ <br /> k BASE EXPLANATION AMOUNT DUE CHECKED <br /> - DATE - TE REMITTED AMOUNT <br /> FEE r'`.11 4 <br /> LESS. i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER - <br /> 4 / <br /> Received by Date + Receipt No. Permit No Issuance Hate Mailed Deliver <br /> APPLICANT—RETURN ALL dOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1501 E.HAZELTONN�AY�P..O.Byox 20.08 STOC ON,CA 9 01 <br />