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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Nan-Transterable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEP7AGE <br /> LIQUID WASTE W <br /> A p'p I I c a t;�,115is hereby—made to carry on business in the jurisdictional area of the San Joaq ui n Local Health District <br /> r Business Name (DBA) 10�— ��E� � Address-/7DS S. / �E.G��i7^ <br /> aOwner r Address���5 S �'� 4 <br /> Firm Partners, Addresses and Tele hone Numbers <br /> a. Business Telephone No. � r��1� Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) ��6-&/ Title S� Date <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 <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 /> 4. WSANITATION PERMIT <br /> Job Addressssl/Location _u ef7;9.:e-S4.,v <br /> Owner Address C'�� /�!C/7 �L Address 3 �nzt -Sd d �C <br /> SEPTIC TANK ❑ CESSPOOL t7 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ] <br /> PERMANENT ❑ TEMPORARY 19 NEW 1:1REPAIR OTHER Sk/n P <br /> rw <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 a <br /> Operator Name Where Certified Q <br /> Plant Location 3 <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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws ules and regulations o the San Joaquin Local Health District. <br /> /tJ1 s <br /> APPLICANT'S SIGNATURE X L <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 REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER <br /> OTHER <br /> h'k/�vl <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Dehv ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES I Algel E.HAZELTON AVE.,P.O.Box 2009 5T0 TON, A 95 <br />