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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. I <br /> APPLICATION <br /> p (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is reby�made t9 carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name ( A) f Address � "k 7! -7 <br /> aLy <br /> Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 6r-xy j Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> PI,4 ase check Applicable Category (1-7) and Fill in the R14ired Information <br /> 1A ❑ 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. CAL, Licc,se Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2.k El PUMPER YARD <br /> Follr July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> I <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 Lcation Test Date/Time I <br /> 4. LJ SANITATION PERMIT <br /> Job Address/L ation 7,61Z 2.t <br /> Owner e Address q Q111 <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELDSPAGE PIT El PACAGE PLANT <br /> ❑ PERMANENT 11TEMPORARY 13NEW L'REPAIR ❑ OTHER <br /> 5.11 ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6.�E ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified ) <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7J ❑ LAUNDRY For July 1, -June 30, 19 3 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑I! DRY CLEANING, Chemicals Used/Amount/Mo. r ; <br /> � t <br /> ) <br /> I hereby certify that I have prepared this application and that the work will be done in ac�ord nco with Sart Joaquin County <br /> ordinances, state laws, and rules an egulationsof theJo quin Local Health District, <br /> APPLICANT'S SIGNATURE X �JJ <br /> I� i, <br /> I <br /> FOR DEPARTMENT USE ytQri!�,Y/&,eceived <br /> Fee IS Due: 11ANNUALLY ❑ PER UNIT PER SITE ❑.EACH 3nTiaBy January 31 ❑ July 1 &Received By July 31 <br /> Y <br /> BILLINGI TAN E REMIT$ a <br /> BASE EXPLANATION -DATE REMITTEDAMOUNT DUE CHECKED <br /> T <br /> AMOUNT <br /> ill <br /> FEE <br /> d <br /> LESS p <br /> PRORATION <br /> PLUS�.--- y. <br /> PENALTY <br /> OTHER <br /> f <br /> OTHER y <br /> Of4viLL } <br /> - G _- a <br /> Received by 'Date Receipt No. Permit No. ( I55 nce D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:--,ENVIRONMENTAL HEALTH PERMIT/SERVICES 160.1_E.HAZELTON AVE.,P.O:Box 2009 iSTOCKT ,CA 95201 - - <br /> ,� �.- <br />