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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> M $ � e" (For Non-Transierable, Revocable, and Suspendable) <br /> It - ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE 7?— SAO- <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) Ra1L-90 ii JtL, Own urtvCrYAfaress <br /> aOwner Ii Address I EIS-00 At. 773 izLVe_- -CM i <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 0A 7 Emergency Telephone No. <br /> d Contractor Licence No. i <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Intormation P <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. I CAL. License No. CAL. License Renewal No. f <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 t <br /> �- <br /> No. of Vehicles Stored 1 <br /> .No. of Chemical Toilets Stored <br /> 3. 19 PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time ' <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address tJ <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 `� t <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. —� <br /> On <br /> hereby certify that I have prepared this application and that the work will be don% in c ordanc with.San Joaquin County 4 <br /> 4. <br /> ordinances, state laws, and ru a eg gtions the San uin Local Health Di ri .�i <br /> APPLICANT'S SIGNATURE X r t <br /> FOR DEPARTMENT 1!� O <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH J uary 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> BILLING M ANCE $ REMIT <br /> BASE EXPLANATION PATE , ATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �✓fi�j Q 4 <br /> LESS l s <br /> PRORATION <br /> ' R <br /> PLUS <br /> PENALTY 4 [ <br /> OTHER _ <br /> OTHER <br /> M ,V, qlldhl ' 73 7 <br /> Received 4y..,,-, Dat - f`- Receipt No. Permil No. Issuance DateMailed Deliver d- <br /> APPLICANT -RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E-HAZE_LTON AVE.,P.O Boa 2009_,z.STOC TON,CA 95201 , <br />