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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ;0.,, APPLICATION <br /> h (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 /> yBusiness Name-(DBA) o 'r- S6 Address <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> 4 Contractor Licence No. Gd- S�6 O <br /> .Applicants Name (Print) AP e r�'r�0lr-! Title Date �— -7— 8a <br /> Please check Applicable Category (1-7) and Fill in the Required Information 10. <br /> I 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 03 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse 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 l <br />{ R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> 1 Test Location Test Date/Time <br /> 4. 53 SANITATION PERMIT 13 <br /> Job Address/Location yve <br /> M <br /> Owner tAddress <br /> I SEPTIC TANK ❑ CESSP OL ❑ LEACHING FIELD 1:3 SEEPAGE PIT 0. PACKAGE PLANT <br />{ ISI PERMANENT ❑ TEMPORARY 11 NEW ❑ REPAIR l$ OTHER Fi�Ter Epi <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br />( Type Construction Disposal Site <br /> ` No. of Units Equipment Storage/Cleaning Location(s) j <br /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 e� <br /> Operator Name Where Certified OM <br /> Plant Location N <br /> Plant Capacity 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. <br /> ( <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, and rules re lation of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE - <br /> Y <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER l <br /> Receiveedby Date Receipt N. r ,,Permit Nossuan <br /> � Ice Date 7maded D ed <br /> F APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AYE.,P.O.Box 2008 $ CKTON,CA 8520 ,j.¢ <br /> 1 , <br />