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W Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 1 92s, (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati hereby m de to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ;Business Name{DBA} l��d�� ,- <br /> aOwner �C� Q� ets- Address— / '.00 <br /> _ <br /> R�'r, Address <br />` J Firm Partners, Addresses and TelephoQe�Numbers <br /> CL Business Telephone No. d $t1! <br /> Emergency Telephone No. <br /> -Contractor Licence No. <br /> i a <br /> L Applicants Name (Print) Title Date l <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 /> I <br /> Serial No. CAL. License No. <br /> CAL, Lica.^3e 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. 1:1 SANI TATiON PERMr�r <br /> Job Address/60cation /�.70 So(_ ii 4'4,U'3 (Q ^(5 <br /> Owner IV Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE'PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 4 <br /> Type Construction I Disposal Site_ /9L.>L) t9 rs ���_5v/'U G <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 " <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 prepared this application anA that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,.and es and regulations of the n Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> 11PA OLO�_' <br /> f FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received B Januar 31 <br /> a; <br /> Y Y ❑ July 1 &Received By July 37 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT i <br /> ,,�2 DATE DATE REMITTED AMOUNT DUE CHECKED rL <br /> FEE `! �� �i'yytQX/ Ij AMOUNT <br /> LESS <br /> PRONATION <br /> PLUS <br /> PENALTY <br /> OTHER S <br /> OTHER - <br /> r <br /> i <br /> Received by - ate Receipt No. Permit No. Issuance Date Maiied ivered <br /> Del - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.HAZELTON AVE.,P.O.Boz 2009 - STOivared CA 95201 <br />