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r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. T z <br /> APPLICATION r <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> �. 4' LIQUID WASTE <br /> Application is hereby made to car on business in the jurisdictional area of the Sin Joaquin Local Health District <br /> FBusiness Name (DBA)� r.._�� G E Address <br /> a OwnerJ �— _C�t�'a2 Address . L�7 <br /> J Firm Partners, Addresses and Telephone Numbers d <br /> IL Business Telephone No. ; <br /> I Emergency Telephone No, <br /> Contractor Licence No. <br /> a <br /> L Applicants Name (Print) /` Title «/ 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.-LCAL. No. ..r _ ^CAL'�Li4 ;e Renewal No. <br /> Capacity P Y 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 _ I <br /> R.S. or R.G.E. Name �r R.S. or R.C.E. No. I <br /> Test Location 'fes <br /> Test Date/Time ! ! <br /> 4. ❑ SANITATION PERMIT t _ <br /> Job Address/Location' AVC /C ,V1 .3 <br /> s. I <br /> ' <br /> Owner . .- Address <br /> SEPTIC TANK •❑ CESSPOOL O LEACHING FIELD 11 SEEPAGE PIT ❑`PACKAG PLANT '� r <br /> ❑ PERMANENT ❑ TEMPdRARY ❑ NEW ❑ REPAIR ❑OTHER 'V <br /> i n <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction r 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 V{rhere Certified. f I <br /> Plant Location <br /> Plant Capacity No. Units Served K I <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. � f 1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ° 1 <br /> 3 � i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County t <br /> ordinances, state laws, and rules an regul ions of t e San Joaquin Local,Heaith District. <br /> APPLICANT'S SIGNATURE X "V Y <br /> t <br /> FOR DEPARTMENT USE ONLY + <br /> ' r j <br /> Fee Is Due: 11 'P <br /> ANNUALLY ❑ PER UNIT ER SITE ❑_ EACH I <br /> _ ❑ January 1 &Received By January 3.1'_ ❑=Ju1y 1 9 Received By July 31 + <br /> L a BILLING REMITTANCE $ '- REMIT - t <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE I <br /> LESS i <br /> PRORATION { 1 <br /> PLUS <br /> PENALTY { <br /> OTHER ' <br /> -ems_ T, r•-'- - .., ....�c,.,.,,,,,.,;,-_ ....�.: - _ .,.. ,.»�-,�,-v.- - .�,.,.,�.-... .. - ... <br /> OTHER <br /> ' k <br /> Received by Date n Receipt No. +permit No.. - U691—i. Mailed t e <br /> ,APPLICANT—RETURN'ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 -S TON,CA 201 y <br />