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.... <br /> Applications Will Be Processed When Submitted Properly omp •r �� tr of r -I <br /> APPLICATION _ <br /> r (For Non-Transferable,Revocable, and.SLTsliendabfe)* k - zl:'-SEPTA•GE <br /> ENVIRONMENTAL HEALTH PERMIT {{{/ <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the an J aquin Local�Health District �Z <br /> Q• 1✓1� � Z rr _—Address 4 <br /> N Business Name (DBA) <br /> Address <br /> z Owner <br /> 0M Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. t , <br /> CL Business Telephone No, 07 0 <br /> Q T _ - <br /> Contractor Licence No. O Date4 <br /> ,i Title <br /> Applicants Name (Print) (� <br /> Please check Applicable Category (1-7) and Fill in the Required Information -. �, yib <br /> 1. ElPUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 -- - -Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity-- Gal.,Weights t Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ? I <br /> For July 1• <br /> June 30, 19• <br /> No. of Vehicles Stored 4 a <br /> No. of Chemical Toilets Stored <br /> 3• ❑ PERCOLATION TEST -- r R.S. or R.G.E. No. I <br /> R.S, or R.C.E. Name T ' <br /> Test Date/Time <br /> Test Location <br /> 4. UMANITATION PERMIT l <br /> Job Address/Location �- ���' dYAddress r <br /> Owner Me•• 5M ITiI-� y ❑'PACKAGE PLANT' ' <br /> # ll SEPTIC TANK C1 CESSPOOL ❑ LEACHING FIELD a SEEPAGE PIT <br /> ®'PERMANENT ❑ TEMPORARY ❑ NEW € B"1EPAiR " ❑ OTHER <br /> t 5. ❑ CHEMICAL TOILETS For July 1, =June 30, 19 { <br /> Type Construction Disposal Site F <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT ' For July 1, -June 30, 19 F <br /> Where Certified . <br /> Operator,Name <br /> Plant Location ^o- s <br /> No. Uriits Served <br /> Plant Capacity <br /> ! 7. ❑ LAUNDRY FortJuiy_1, -June 30,.19_.__ <br /> SIZE: ❑ Less Than'.1,000 Sq. Ft., ❑ More Than 1,000 Sq."Ft. <br /> 11 DRY CLEANING,Chiemicals Used/Amount/Mo. <br /> I <br /> � i hereby certify that I have prepared this application-and that the work will be done in accordance with San Joaquin Quin y <br /> ordinances, state laws, a r les and re tions 0 San Jo in �Glealth District. <br /> APPLICANT'S SIGNATURE X <br /> 7_7 < <br /> 9 FOR DEPARTMENT.-USE ONLY,r <br /> Feels Due: [I ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Receiv REMIT <br /> �ry 31 <br /> } -�'• / BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> q` , ,,r' ,�s j^� .� JK'•r"'BASE- EXPLANATION PATE DATE <br /> REMITTED $•t'ANIQUNT <br /> L L <br /> FEE L4 <br /> LESS '.. <br /> ` PRORATION Y,.( <br /> PLUS v <br /> PENALTY <br /> OTHER <br /> ,rr OTHER _ ,, •�• - - � - <br /> _ _ d _.._ _... <br /> Received by <br /> Date Receipt No. Pe it o. is uance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2609" $TOCKTON CA 95201 <br />