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Applications V6=,jll Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Vi <br /> i <br /> APPLICATION <br /> (9-or.Non-x'Sansferable, Revocable,and Suspendable) <br /> ENVIROPUMENT�AL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business`Name (DBA)J>Ar. �i4i21 51-1 SoN,M, M,01-_ Address *?©. SC'k 444!ZO S-TKri, gSZOI <br /> } a Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers _ <br /> E Business Telephone No. 46!2 A ���1.,_.... Emergency Telephone No. <br /> #. a <br /> Contractor Licence No. Z:E-,Zt <br /> L Applicants Name.(Print) 4. 4511' A,� --- - Title:SC-?__ LhdAte_--_4_R. Date I0" 1- <br /> Please heck 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. ^ter <br /> Capac ty Gal., Weights & Measures No. <br /> SEquipment Parking Address <br /> �2." `❑ PUMPER YARD.: <br /> For July 1, June 30, 19 <br /> No. of__Vehicles Stored <br /> No. of Chemical Toilets Stored r <br /> - °3. ❑'PERCOLATION TEST <br /> R.S. or R.C.E. Name F - _ R..S.or R.C.E. No. <br /> '-Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> :Job Address/Location 1(61 S O. C4-F/ RID2`;'1Z i y, S'1-1JJ 4SO 1�c1�1 U/- e _44RTak <br /> 11 Owner F L - i Y Address 'SAM e <br /> r ❑ SEPTIC TANK ❑ CESSPOOL,;' LEACHING FIELD BSEEPAGE PIT ❑ PACKAGE PLANT <br /> t CPERMANENT ❑ TEMPORARY ❑ NEW 2--REPAIR ❑ OTHER <br /> ' 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> r Type Construction Disposal Siteon t <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 /> a <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 /> r N <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, d rules and regulations he San aqu� Local Health District. C <br /> APPLICANT'S SIGNATURE X - y `-'� <br /> f � 2 <br /> FOR DEPARTMENT USE ONLY <br /> (k <br /> .Fee Is Due- ❑ ANNUALLY ❑ PER UNIT 0 PER SITE ❑-EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> F -- � REMIT <br /> 444 <br /> BASE EXPLANATION BILLING REMITTANCE $DATE DATE ITTED 'AMOUNT DUE CHECKJeD <br /> AMO T <br /> FEE <br /> LESS <br /> PRORATION - • <br /> 'PLUS 7 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1631 o <br /> Received by Date Receipt No. - Permit No Imanco Date Mailed IDelivereA <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bol 2009 STOC ON;CA 952 <br />