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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application." <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL 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 /> H Business Name (DBA) 12 A 1PAfQI21S9 > S,00<., =AJC . Address © Soy, 1450 STT' gSZ.QJ <br /> T <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 4"- %o-7 Emergency Telephone No. j <br /> Contractor Licence No. ZSLII 343 r <br /> . 3T. <br /> Applicants Name(Print)��il(r'Ey 'g- S1 Ad,s Title Date <br /> Please check 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. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test�LocAaa on Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location �/ AC; Z.✓CJ, T�'y <br /> Owner�r/J�.6�L �sELFS�S!J Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ,OTHER jDE5-1iiidy stip T1G "mwj< "A <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 'r <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 A <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I h e prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,"n rules nd regul ions the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE 11 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE G 1� <br /> LESS /i <br /> PRORATION I l� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> aM <br /> - Received by Date Receipt No. Pe i No. (Issuancla Date Mailedeliver <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVEi,P.O.Box 2009 - STOC ON,CA 9 201 <br />