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v <br />Applications Will Be Pj* JsedWhen Submitted Properly Completed. tiesure Iosign rirc+NN••ti•• cps APPLICATION FEB 14 80 L4 For <br />Non-Transferable,Revocable, and <br />Suspendable) <br />SEPTAGE I SAN JQAQUI i LOCAL <br />LIQUID HEALTH <br />PERMIT LIQUID WASTE r1 HEAl. <br />T,ih <br />D ST% <br />g <br />R Appllcatl n Is ere a tcarryonbusinessinthejurisdictionalareaoftheS,a n_Joafqu_i n ocal Health Di trict r Business Name (DBA) 7- Address. <br />L z Owner Address a J Firm <br />Partners, Addresses <br />and <br />Telephone <br />Numbers aBusiness Telephone No. 1 Emergency Telephone <br />No.Contractor Licence No.Applicants Name (Print) <br />Title e Date <br />1 'Please check <br />Applicable Category (1-7) <br />and Fill in the Required Information 1. PUMPER VEHICLE PERMIT REGISTRATION (FOR <br />EACH VEHICLE)For July 1, June 30, 19 <br />Disposal Sites Description(Make/Yr., Color)CAL. License <br />Renewal No.Serial No. CRL. License No.Capacity <br />Gal.,Weights &Measures No.Equipment <br />Parking Address 2. .PUMPER YARD <br />For July 1. <br />June 30, 19 <br />No. of Vehicles Stored No. of <br />Chemical Toilets Stored 3. <br />PERCOLATION TEST R.S. or <br />R.C.E. <br />No. W R.S. or R.C.E. Name Test Date/Time W Test Location <br />to 4. SANITATION PERMIT <br />Job Addre s/ <br />Locat' n Owner <br />U Address C'SEPTIC TANK <br />ESSPOOL 2 LEACHING <br />FIELD SEEPAGE PIT 13 PACKAGE PLANT L1O PERMANENT TEMPORARY GVNEW REPAIR OTHER <br />4 5. CHEMICAL TOILETS For July <br />1,- <br />June 30, 19 dl Type Construction Disposal Site No. of <br />Units Equipment <br />Storage/Cleaning <br />Location(s)6. PACKAGE TREATMENT PLANT For July <br />1, -June 30, 19 Where Certified Operator Name Plant Location <br />No. Units <br />Served Plant <br />Capacity 7. <br />LAUNDRY For July <br />1, -June <br />30, 19 SIZE: Less Than 1,000 Sq. <br />Ft., More Than 1,000 Sq. Ft. DRY CLEANING, Chemicals Used/Amount/Mo. <br />I I hereby certify that I <br />have <br />prepared this application and that the work will be done in accordance with San Joaquin Coun y ordinances, state laws, an rules and <br />regulatio of t e San Joa uin Local Health District.APPLICANT'S SIGNATURE X v FOR <br />DEPARTMENT USE ONLY Fee <br />Is <br />Due: ANNUALLY PER UNIT <br />lyPER SITE EACH January 1 &Recewed By January 31 Juiy 1 &ReceivedREMITuly 31 BILLING REMITTANCE AMOUNT DUE CHECKED BASE <br />EXPLANATION DATE DATE REMITTED AMOUNT_ <br />FEE LESS Can PRORATION PLUS PENALTY <br />OTHER <br />F' <br />tOTHER <br />5 <br />Received <br />by <br />Date Receipt <br />No. <br />Permit <br />o, Issuance Date Mailed etivere 1601 E.HAZELTON AVE.,P.O. <br />Box 2009 STOCKY N,CA 9 APPLICANT—RETURN ALL COPIES TO: ETIVIRONMENTAL <br />HEALTH PERMITlSERVICES ___ y