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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �y ' <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) 4 <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applica � is h reb mNde to carry on bues In the I I Ictional area of the SanJoaquinLocal He Ith Distric <br /> Uo <br /> N Business Name (08A) the <br /> Address /�4� <br /> a Owner Address1W Sz9V61-12Z <br /> Firm Partners, Addresses and TelepLoll [ <br /> Q. Business Telephone No. �� Emergency Telephone No. jl <br /> Contractor Licence No. > <br /> Applicant's''Name (Pririt) * ^' Title �. Date <br /> Please check,App1Iic6bI6.�Categ`ory(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., Calor) - <br /> 'Serial No. CAL. License No. CAL. License Renewal No. <br /> 'Capacity °Gal., Weights & Measures No. A <br /> 'Equipment Parking Address <br /> I2. ❑ PUMPER YARD t <br /> IFor July 1, Jurie 30, 19 , <br /> No. of Vehicles Stored ` <br /> No. of Chxemical Toilets Stored 'k` <br /> 3. ❑ PERCOLATION TEST 'k4 X j <br /> R.S.or R.C.E. Name ` R.S. or R.G.E.No. <br /> (Test Location Test Date/Time ) <br /> t '# '•sem <br /> 4. SANITATION PERMIT <br /> 'Job Address/Location 647-0 —+f�e <br /> Owner 041� &,t,4 0,E01 Address. ��� <br /> 51 SEPTIC TANK ❑ CESSPOOL W LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> .Or PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER I _ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s),- <br /> 66. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> OperatoriName Where Certified � ) <br /> Plant Location <br /> Plant Capacity No. UnitsYSe ved <br /> 7. ❑ LAUNDRY For July 1, -IJune 30, 19— <br /> ^ SIZE: C] Less Than 1,000 Sq! Ft., 11More Tha_6:1,000 Sq, <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.. - 4L' `#�_ r <br /> WkN <br /> !— 7f 1,1010' <br /> 1 hereby certify that I have prepared this application n and that the work will be done in accordance with San Joaqui C unty <br /> ordinances, state laws, and ules and regul tions of a San Joaquin Local Health Distrct. 's, <br /> APPLICANT'S SIGNATURE X <br /> t <br /> ~ � FOR DEPARTMENT USE ONLY <br /> s- <br /> Fee IS Due: El ANNUALLY '❑ PER.UNiT�� a •,RER SITE 0 EACH ❑ January 1 &Received By January 31 El July 1A&Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> j AMOUNT DUE CHECKED <br /> BASE EXPLANATION - DATE DATE REMITTED - - <br /> AMOUNT <br /> FEE "7 <br /> LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> e- -- <br /> [.'""` —9�*:_ - � ��--�� t <br /> OTHER ; '`"`3+' .fi'r#-- •r 1k x� 1 I 3 <br /> Received by Date Receipt No. Permit No. a Issuance Dae Mailed" alive ed <br /> F <br /> yk APPLICANT—RETURN ALL COPIES TjOi ENVIRONMENTAL-HEALTH-PERMIT/SERVICES 1 --��-.1601 E.HAZELTON AVE.,P.O.aaK 2009 'STOC TON, 1 A, <br />