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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. i <br /> h . APPLICATION 6 <br /> (For Non-Transterable, Revocable, and Suspendable) i <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatiohereby made to Car on business in the jurisdictional area of the San Joaquin Local Health District <br /> �Business N� (DBA) <br /> c.. l�A�f j `S -Ck ter Address / u / �T i�•�: . Y <br /> i Owner_ in CA ftp I Ic Address <br /> K <br /> Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephone No. <br /> mBusiness Telephone No. <br /> � Contractor Licence No. .2 I <br /> Applicants Name (Print) 'lm C'`�R�,l� 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. License No. GAL. Liccae 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 4 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMITVA <br /> Job Addre Location F� I��� Ay n�T�c�� <br /> Owner �0NA)ie- 12 AMSeY Address Yhle \` <br /> 13 SEPTIC TANK 11CESSPOOL ]A LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ' <br /> ❑ PERMANENT ❑ TEMPORARY ® NEW ❑ REPAIR ❑ OTHER1 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19, rr _ <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 <br /> Where Certified <br /> Operator Name <br /> Plant Location J <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 /> I't <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> i <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, anq_ s and regulationsA the Sa Joaquin 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 &ReceiveRdE;BNyI Juiy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �� I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receivetl by Date Receipt No, Permit No <br /> Issuance Dale Mailed 5DeliveAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1661,E.HAZELTON AVE.,P.O.Box 2009N,CA• 201 <br />