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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (Far Non-Transferable, Revocable, and Suspendabte) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE r- <br /> LIQUID WASTE <br /> Applicata I here y ma carry,on iness in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DB ) . t� ,e i Address , J� .. I � �� �� <br /> -,a Owner. Address .-17-0,51 �i ';iO4!5:;4 AVO; <br /> J-Firm Partners, Addresses and Telephone_Numbers _ <br /> a Business Telephone No. � ���� Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name {Print) '`s Titled Date <br /> 9---32:7 <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. CA <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ....»w. •-_ , <br /> For July 1, June 30 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored r <br /> 3. ❑ PERCOLATION TEST} /e <br /> R.S. or R.C.E. Name S '^ —1 i R NI,R.C.E. No. #. [' <br /> V <br /> Test Location Test Date/Time . <br /> 4. IdSANITATION PERMIT <br /> Job Add r /Location # 4S_, ® d <br /> Owner ' <br /> � Addresses <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGI= PLANT s <br /> PERMANENT [] TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER T. _ <br /> 13 CHEMICAL CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site r <br /> yt <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6t❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name - —" " ^'""—"_"" """ '""" ""'"'Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served'" <br /> 7.11 LAUNDRY For Jul;.1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. R w <br /> E1,DRY CLEANING,Chemicals Used/Amount/Mo. <br /> X. <br /> 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, a uses and regulations of the S n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> � S <br /> i <br /> FOR DEPARTMENT USE ONLY I <br /> Fee J. D4.,13 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &.Received By January 31 '❑ July 1 &'Received By July 31 <br /> -1 BILLING REMITTANCE REMIT <br /> {i <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> r r•,i _ � j AMOUNT <br /> FEE ........... r 6� <br /> LESS <br />' PRORATION ; <br /> r� [i�f <br /> PLUS <br /> OTHER` <br /> t lr, 1Yfl M11.7 <br /> Received by Date _ Receipt N0. Permit N ssuan a Date Mailed Deliv ed l <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STO TON,CA 95201 •� <br />