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r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.T <br /> - APPLICATION- <br /> - (For Non-Transferable, Revocable,'and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appli ti is hereby made to rry on business i e jurisdictional area of the Joa Local H�gl tri <br /> rn Business Name (DBA) fc� _ Ut O 4 <br /> z Owner – Address C <br /> c Addres <br /> J Firm Partners, Addresses and Telephone Numbers �` <br /> w r + <br /> Q Business Telephone No, 46 1 <br /> Contractor Licence No. <br /> Emergency Telephone No. [� <br /> L Applicants Name (Print) A Iz <br /> Please check Applicable Category (1-7)and Fill in the Required Information $Itle Date <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. a <br /> I Capacity CAL. License Renewal No. <br /> Gal., Weights & Measures No. <br /> Equipment Parking Address t <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 34, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name <br /> R.S. or R.C.E. No. <br /> TestLocation Test Date/Time <br /> 4. C4 SANITATION PERMIT <br /> Job Address/Location <br /> Owner Ce4 J� l — dip <br /> `^ <br /> y �Address G �- <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT 6!4 <br /> 0 PERMANENT ❑ TEMPORARY NEW ❑ REPAIR El OTHER <br /> 5 ❑ CHEMICAL TOILETS For July 1 June 30, 19 v <br /> Type Construction Disposal Site �+ <br /> No. of Units Equipment Storage/Cleaning Location(s) e- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, June 30, 19 <br /> Operator Name <br /> Plant Location Where Certified lJ� <br /> Plant Capacity <br /> No. Units Served <br /> 7. El LAUNDRY For July 1, -June 34, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. 1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 4– <br /> 1 hereby certify that I h ve prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state la s, rul d re lations of the S J quin Lo I Health District. <br /> APPLICANT'S SIGNATURE X r <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 /> BASE EXPLANATION BILLING REMITTANCE REMIT <br /> DATEDATE REMITTED AMOUNT DUE CHECKED <br /> S r - <br /> FEE AMOUNTS <br /> f 1 <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY 2 J <br /> OTHER <br /> OTHER i <br /> Sar �, <br /> Received by Date Receipt No- Permit No f <br /> ssuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES s r <br /> 1601 E.HA2ELTON AVE.,P.O. CA 85201 w <br /> ��l !tom.,i <br />