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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 1 7�j— <br /> (For Non-Transferable, Revocable, and Suspendable)1,\ �1 <br /> ENVIRONMENTAL HEALTH PERMIT L SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carryon b siness in the�jur�isdictional area of the San Joaqui Local Health District <br /> F Business a (DBA) IG7Lr ra ctsn Address r#_010 �lal/ Qf� /QCl}Ado t� o <br /> aOwner � Address <br /> ..� <br /> u Firm Partners Addresses and Telephone Numbers ,L ar S.IIII —.2�I/ c fn — GAoijm <br /> A. J 3Co��Y143 d- r <br /> Business Telephone No. (f, Emergency Telephone NO. .SiQIV1[, <br /> Contractor Licence No. o <br /> Applicants Name (Print) p <br /> Title V;� Date �' s'7 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. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD I't <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�,Loation Test Date/Time <br /> 4. � SANITATION PERMIT <br /> Job Addres ocation C _ <br /> Owner Address �5291KC _ J <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD P9 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW GYREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 P <br /> Type Construction Disposal Site _ C <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 O <br /> Operator Name Where Certified <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. _ <br /> I hereby certify that I have pr ed this appliis tio�an that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and an egulatio he an Joaquin 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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE (•[ A• ,N �� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issu nca D to Mailed a rver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.H ELTON AVE.,P.O Sint2009 ST C ON,CA 20 <br /> i ��� ff <br />