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J Applications�Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - tI <br /> T APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) +Q <br /> -:.:�.o-:: ,ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> F-f-r�u-0 -c,Jr= - LIQUID WASTE <br /> f _ .aL­ o .D <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Name (DBA) Address . <br /> a Owner r r` r-'ONQ*-.. Addresses S50 rL7�vv,,czr- 1 L! W <br /> / r�rse11�i'f_ _ <br /> Firm Partners, Addr sses and?Telephone Numbers <br /> aBusiness Telephone No. �f"L 2)-_G4-7 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name(Print) Title Date " <br /> Please check Applicable Category (1- )and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Ii Disposal Sites <br /> Description(Make/Yr., Color) q <br /> Serial No. CAL. License No. CAL. Lica;se Renewal No. i <br /> Capacity II Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ;I <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored r <br /> No. of Chemical Toilets Stored _ <br /> 3. ❑ PERCOLATION TEST �� G <br /> R.S. or R.C.E. Name I R.S. or R.C.E, No. <br /> Test Location Test Date/Time <br /> 4. X SANITATION PEWI <br /> Job Address,Location a c, R ` d if I h C-$ U te® 41 k <br /> OwnerAddress { <br /> ASEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ? (j <br /> Type Construction I; Disposal Site + �� <br /> No. of Units I; Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 tC <br /> Operator Name Where Certified , <br /> _Plant Location <br /> Plant Capacity a 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 /> : <br /> I hereby certify that I hav prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d ules and regul ti ns of the San Joaquin Local Health District. ! <br /> APPLICANT'S SIGNATURE X ' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT i$PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> li <br /> FEE <br /> LESS �I <br /> PRORATION - Il <br /> PENS I! <br /> PENALTY <br /> OTHER Ii <br /> �6. <br /> OTHER I'v <br />�'�-� Received by Date _ Receipt No.. Permit No. Issuance Date Mailed Delivyted /I <br /> D.PPLICANT—RETURN ALL COPIES TO:_ ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO KION,C 95201 <br />