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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> �,- APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is here made to ca on b si ess in the jurisdictional area of the San Joa in I Health District <br /> F Business Nara BA) _ � "� Address E <br /> z Ownera �, 7:s�o V1 C's Addres n <br /> 4 <br /> J Firm Partners, Addresses and Teleph ne Number r <br /> IL 19 t(7 Emergency Telephone No. �� <br /> a Business Telephone No. <br /> C 4'1--3 2F�a77 <br /> Contractor Licence No <br /> Applicants Name(Print) O � Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information s <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 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location �Sc ��' <br /> Owner Address <br /> 11 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 13 SEEPAGE PIT 1-1 PACKAGE PLANT <br /> ❑ PERMANENT E] TEMPORARY IJ NEW REPAIR OTW,E �� � <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �'""'%�/�C S'K 10 sv i'h <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 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 pre ed this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule an egulations of toe San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dale Receipt No. Permit No. Islauance Lgate Mailed eliver <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC ON,CA 201 <br />