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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 SEPTA-OE, <br /> LIQUID WASTE ` <br /> Application is hereby made to carryon business in the jurisdictional area of the an Joaquin Local Health District r� <br /> rn Business Name {DBA) / f�•� Z�/S fy ;10A � _Address -d. fox /V,5[ <br /> tOwner Address <br /> z Firm Partners, Addresses and Telephone Numbers 1 <br /> aBusiness Telephone No. 446161— CJ Emergency Telephone No. 1 <br /> Contractor Licence No. <br /> LApplicants Name (Print) 1AJ <br /> Title Date 7—/6 —5Z-10 <br /> Please check Applicable Category (1-7)and Fill in the Required Information `J <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 t a <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 Location _ Test Date/Time <br /> M <br /> 4. Ca SANITATION PERMIT ....� <br /> Job Address/Location 140 41— <br /> Owner 4-' <br /> sOwner -4-'C Z J! J Address <br /> o: <br /> ❑ SEPTIC TANK ❑ CESSPOOL BLEACHING FIELD C1 SEEPAGE PIT ❑ PACKAGE PLANT <br /> BIPERMANENT 11 TEMPORARY 11NEW EREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July.1; -June 30, 19 <br /> Type Construction Disposal Site ' <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT; For'July 1, -June 30, 19 <br /> Operator Name. <br /> Where Certified N <br /> Plant Location `` ; U of <br /> Plant Capacity ` <br /> P Y No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., . ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. k <br /> I <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, d rules and regulations of the an Paquin Local Health District. <br /> APPLICANT'S SIGNATURE X - <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 g REMIT <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKEDAMOUNT ' <br /> FEE LAW— <br /> LESS <br /> PRORATION k <br /> PLUS :j <br /> PENALTY I <br /> OTHER t <br /> r ` F <br /> OTHER !1 <br /> Received by - Date Receipt No. _-Permit o. I Issu nce Date - Mailed Deliver <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1fi01 E.HAZELTON AVE:,P.O.Box 2409 STOC ON,CA 9 01 <br /> I �. <br />