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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) SEPTAGE j <br /> ENVIRONMENTAL HEALTH PERMIT p <br /> i LIQUID WASTE p <br /> I SiApplication hereby made to, rry on business in lae jurisdictional area of the San Joaquin Local Health District <br /> '� ii 0. Address i <br /> Business Name(DBA) >6 . y <br /> Owner I it Address <br /> Firm Partners,Addresses arid'Telephone Numbers <br /> Business Telephone No. �y �-- Emergency Telephone No. <br /> Contractor Licence No. Date <br /> Applicants Name(Print) l� rn^ -9 -�-C l Title <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Colo) 'I ' <br /> IK. CALLicese No. CAL.License Renewal No. <br /> I, . n . <br /> Serial No. I <br /> Capacity Gal.,i Weights&Measures No. <br /> Equipment Parking Address @. <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30,19 <br /> No.of Vehicles Stored it li '1 <br /> Y ' <br /> No. of Chemical Toilets Stored - <br /> 3.--O-PERCOLATION TEST R.S.or R.C.E.No. <br /> " - <br /> 11 <br /> R.S.or R.C,E.Name <br /> Test Location = 11 Test Date/Time <br /> 4., 17 SANITATION PERMIT <br /> Job Address/Lo ion 11 1 <br /> ` Owner ' - Address <br /> ❑ SEPTIC TANK ❑ CjSSPOOL li 13LEACHING FIELD 13SEEPAGS PIT ❑ PACKAGE-PLANT <br /> LZ PERMANENT 13 TEMPORARY it 13NEW REPAIR OTHER L '� ►�g� <br /> ❑ CHEMICAL TOILETS For July 14-June 30, 19 - <br /> ype Construction - 41 -- - 4— "-•"" Disposai.Site <br /> No.of Units -IL Equipment Storage/Cleaning Location(s) <br /> a 41 ..� <br /> 5. ❑ PACKAGE TREATMENT PLANT II For July 1,-June 30, 19 Where-Certifled <br /> Operator Name . <br /> Plant Location <br /> Plant Capacity ' No.Units Served <br /> r 7. ❑ LAUNDRY For Juljl 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 l have prepared this application and that the work will be done in accordance with San Joaquin County' <br /> ordinances,state laws, a rules and regulati ns of uin local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I I I <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ANN ❑ PER UNIT Ia PER SITE ❑ EACH ❑ January t&Received By January 31 ' July 1&Received 3t <br /> E 'ff REMITTANCE $ - AMOUNT DUE CHECKED <br /> -II BASE <br /> EXPLANATION' <br /> BILLING <br /> DATE REMITTED AMOUNT <br /> FEE'LESS­ <br /> PRORATIONPLUS <br /> ( PENALTY �I <br /> OTHER <br /> OTHER ! <br /> Received by ^l Mance ate Mailed Deliv red <br /> pate Receipt No. Pe41 No. <br /> APPLICANT—RETURN-ALL COPIES TO::, ENVIRONMENTAL HEALTH PERMITlSERViCES , <br /> 1601 E.HAZELTON AVE.,P.O.Rai 2W9 STO KION,CA 96201 <br /> r <br />