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Applications ill Be Processed When Submitted Properly Completed. ure To ign he Appli atidf <br /> APR R 18 <br /> e - (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMITSAN JO AQUIN LO CALSEPTAGE <br /> LIQUID WASTE HEALTH DISTRICT <br /> Application i er by made to car on b si ess in the jurisdictional area of the San Joa ui.n ocal Health District D <br /> N Business Name (DBA) fit/ G Address �J Z6 _10j, <br /> aOwner { U Address C ra+ <br /> 9 Firm Partners, Addresses and Telep ne Numbers s � J <br /> F Business Telephone No. i'7— <br /> CL 2 Emergency Telephone No. <br /> 1 Contractor Licence No. '2 <br /> r <br /> Applicants Name (Print) w L ~ ° Title t- Dates <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> I 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Dis osal Sites <br />' Description(Make/Yr., Color) <br /> Serial No. CAL. Lice o. CAL. Liccse Renewal No. <br /> Capacity Gal.,Weights 8��F>sasure 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 Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT., <br /> Job Address/Loci <br /> Owner Address v <br /> SEPTIC TANK ❑ CESSPOOL ISI LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT �e- C.1-k-4i�eeT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR AU OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site tt�� <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT F r July 1, -June 30, 19 Ic <br /> Operator Name Where Certified <br /> 4 Plant Location or <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ e Than 1,000 Sq. Ft. <br /> 1 ❑ DRY CLEANING, Chemicals Used/Amo t/ <br /> I hereby Y <br /> certif that 1 have prepare his a plication and that he work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules a tions of the Sa aquin 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> q ?a <br /> .� Received-by Date - Receipt No. Permit No. Issuance Date Mailed eliver <br /> t 'APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES' - - 1601 E.HAZELTON AVE.,P.O.Box 2009 . STOCK ON,CA <br />