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p Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> " <br /> APPLICATION <br /> �u <br /> (For Non-Transferable, Revocable,and Suspendabie) I <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> N LIQUID WASTE <br /> *^'Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Bu§iness'Name (DBA) Address <br /> a Owner /r%a.1/ La �%4L �� Address <br /> Firm Partners, Addresses an Telephoneber r r <br /> CL Business Telephone No. ��` P� Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) L j o/�! '�� Title Date -ZU gg <br /> Please check Applicable Category (1-7) and Fill in the Required Information i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June..30, 19 Disposal Sites <br /> Description(Make/Yr.;-Color) 3 i <br /> Serial No. CAL. License No. CAL. License Renewal No. Q <br /> Capacity Gal.,Weights &Measures No. SUV <br /> I <br /> Equipment Parking Address k <br /> 2. ❑ PUMPER YARD P <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST n <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time t <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/E ocation �A G U �-v �� cf <br /> Owner r .Address <br /> .t SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ,9 PERMANENT ,❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction ;Disposal Site r <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 /> E <br /> Plant Location 4, N <br /> Plant Capacity t 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 /> 1] DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Nordinances -laws, an r les and regulations of the San Joa uin Local Health'Di strict. t <br /> y 'Ir <br /> APPLICANT'S SIGNATURE, <br /> i FOR DEPARTMENT USE ONLY J <br /> r <br /> - Fee IS DUe: LlANNUALLY `❑.PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE . ,( EXPLANATION e DATES DATE REMITTED AMOUNT DUE . CHECKED <br /> AMOUNT <br /> FEE <br /> I G� r <br /> LESS <br /> PRORATION <br /> ~'f I <br /> .�r <br /> PENALTYPLUS <br /> ✓ <br /> OTHER <br /> i <br /> OTHER .•.'" ; fRl <br /> r <br /> OAF <br /> - <br /> 1 <br /> Received by - ate -'R_ecelpt No. "_ `� Permit No- - suan a Date Mailed Deliv red O <br /> r r �' <br /> APPLICANT=RET+IJKN ALL COPIES TO t ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO KTON,CA 95201 <br />