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Applications Will Be Processed When Submitted Properly4Complet� Sure To Sign The Application. <br /> APPLICATION=_ <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> r Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) �GG� Address ?8 <br /> F 1 <br /> a Owner_ _. � ��,,� tZAddress - <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> aContractor Licence No. <br /> LApplicants Name (Print) Title date —.2 <br /> Z 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. <br /> CAL. License Renewal No. <br /> Capacity Gal., Weights 8 Measures No. - <br /> Equipment Parking Address - r <br /> 2. ❑ PUMPER YARD <br /> For July 1,- � June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> f 3. ❑ PERCOLATION`TEST <br /> 3 R.S. or R.C.E. Name R.S. or R.0'.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location s yA4,cp 041 Ono A.> <br /> Owr Address .. 7 <br /> SEPTIC TANK ❑ CESSPOOL ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 11 TEMPORARY E] NEW ❑ REPAIR ❑ OTHER f, ;e 1 <br /> 5. ❑ CHEMICAL TOILETS For Juiy 1, -June 30, 19 ` <br />' <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 s <br /> Operator Name -Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served a, <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 accordanceRwiiith San Joaquin County <br /> ordinances, state laws, and rules an regulations of the San Joaquin Local Health District. 4 <br /> APPLICANT'S SIGNATURE X- <br /> x x FOR DEPARTMENT NLY .. <br /> Feels-Due:-❑ANNUAL'L'Y""--❑-PER-UNIT-❑-PER-SITE--❑ EACH­�--,O-January 1-&-Received-By-January-31 El-July-1 &.Aeceiveo-$Y-July 31 <br /> e _ <br /> BIL-LING REMITTANCE _day - 5' REMIT <br /> SASE EXPLANATION UNT DUE CHECKED <br /> REMITTED <br /> DATE <br /> mow ' - .__.r- '-SATE <br /> - - <br /> AMO <br /> �-.a.... •b.--AMOUNT <br /> FEE g �/ <br /> LESS tl6 `Y5 <br /> PRORATION . <br /> PLUS <br />{ PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. ed Permit No. Issuance Date Maileliver'd <br /> APPLICANT—RETURN ACL COPIES TO: ENVIRONMENTAL HEALTH PERM IT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2008 <br /> $TOCKTON,C/A 95201 .� <br /> _ i <br />