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Applications Will Be Processed When Submitted Properly Completed.-Be Sure To Sign The Application. <br /> APPLICATION — = <br /> (For Non-Transierable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is h reby ade to car on busii ess in the jurisdictional area of th San Joaquin Local Health District c— O <br /> W Business Name (DBA) � rl s. Address_ /3�X /scs7] A/ ��_1 I <br /> z Owner Address <br /> a .. <br /> J Firm Partners, Addresses and Tel phone umbers <br /> IL Business Telephone No. �(„r ? r �,7 Emergency Telephone No. <br /> Contractor Licence No. � {^,, ' <br /> L Applicants Name (Print)�C14/ �11xN J0 Title Date zS <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccns,e Renewal No. 1 <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 i <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 /> 4. 9 SANITATION PERMIT �. <br /> Job Address/Lo�ation r ST <br /> Owner � f W-"-S. Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ® PERMANENT ❑ TEMPORARY ❑ NEW ;9 REPAIR IR OTHER F/L71:1' �0 # <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> 0 <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 Where Certified CR <br /> Plant Location <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. 7 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> �1 <br /> I hereby certify that I have prepared this application and that th work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and re ulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> dr <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 - -13 July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> i <br /> OTHER <br /> Received by Date _ Receipt No. Permit No. Issuance Date .'Mailed <br /> Deft red <br /> ADPL{CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOPKTONr201 <br />