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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> a <br /> APPLICATION �'4 <br /> (For Non-Transferable,Revocable, and Suspendable) ( I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SEPTAGE. <br /> LIQUID WASTE <br /> Apphca,� isherea to carry o business in the jurisdictional area of the San Joa uin coal Health District p� <br /> rn Business Name (DBA) f��/C� le seleole Address 174 <br /> aOwner c �A Rte / Address <br /> Firm Partners, Addresses and Telephone Numb6er <br /> IL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> a - ^�t> <br /> L Applicants Name (Print) ff Title - � Date <br /> Please check`Applic'able!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 444 <br /> Description(Make/Yr., Color)' <br /> Serial No. I/CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address >' r <br /> I <br /> 2. ❑ PUMPER YARD f I. <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored s <br /> No. of Chemical Toilets Stored <br /> c!1 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT 5 <br /> Job Add F Location �� 4 S 3 <br /> Owner Address <br /> ❑ SEPTI TANK ❑ CES P OL ❑ LEACHING FIELD ❑ SEEPAGE PIT. ❑ PACKAGE PLANT i <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW E] 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 `t`�,' Where Certified <br /> -- =3 i�'y"'+' '+ �'l"ice. --''" - ►. - N1 r".y"�e".,`_`.n"`.. <br /> Plant Location °7 <br /> No. U <br /> Plant Capacity Nnit' s Served ' <br /> r <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than, ,000 Sq. Ft. ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. y <br /> I hereby certify that I have prepared this application and that-the work will be done in accordance with San Joaquin County <br /> ordinances state laws, ules and regulations f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X f _ <br /> F FOR DEPARTMENT USE ONLY <br /> P4 k <br /> Feels Due: ❑ ANNUALLY II PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31R* ❑ July,:1 &Received By July.31 <br /> A 1 ` REMIT <br /> BILLING REMITTANCE "1$;. �^ `� <br /> PLANATION `3 AMOUNT DUE CHECKED <br /> BASE EX <br /> r DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS �- J 6'. - - <br /> PRORATION / <br /> PLUS <br /> PENALTY � }i <br /> OTHER <br /> OTHER <br /> 779—1 <br /> Received by Date Receipt No. Permit No' _ Issuance Date Mailed Deliv ed <br /> • APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -` 1601..E:HAZE'LTON AVE.,P.O.Box 2009 STO T520t <br /> ON;CA. ' <br />