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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> I. P (For Non-Transterabie,Revocable;and Suspendable) <br /> yrs= ENVIRONMENTAL HEALTH.PERMIT SEPTAC <br /> } LIQUID WASTE <br /> Application hereby nada to carry on_ in thejupj dictional areaof the SaAJoaq m Local Health D' trict <br /> Business Nam (DBA) _4 �� ?"� Address <br /> z Owner ' $1 Address G 7 <br /> a <br /> Firm Partners,Addresses and Telephone Numbers <br /> aBusiness Telephone No. 3� !�' rr Emergency Telephone No. — <br /> Contractor Licence No. 3. <br /> Applicants Name (Print) n el'15 �� Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required tnlormation <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. T CAL. License Renewal No. <br /> Capacity Gal.,Weigtits 8.Measures No. N <br /> Equipment Parking Address B" <br /> 2. ❑ PUMPER YARD lS <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3• ❑ PERCOLATION TEST t <br /> R.S.or R.C.E.Name- R.S.or R.C;E.,No. <br /> Test Location Test Date/Time. <br /> 4. ❑ SANITATION PERMIT o <br /> Job Address/Lcat. n_ �- �, - <br /> Owper / ��.. Address <br /> /SEPTIC TANK ❑ CESSPOOL LEA,(;HING FIELD C7 , <br /> EEPAGE PIT PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY. 13 NEW � REPAIR OTHER <br /> S. 0 CHEMICAL TOILETS For July 1,;-June 30, 19 <br /> Type Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) t <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 /> S)ZE: 13Less Than 1,000 Sq,Ft., 11More Than-1,000 5q.,Ft, <br /> ❑{CRY CL&NING,Chemicals Used/Amount/Mo. <br /> I tleretiy Certify that I have prepared this application„and tF]at<', peworlt will be done`in accordance with San Joaquin County <br /> ordinances,state laws,and rules .regulations of the in Local Health District. <br /> 1� <br /> APPLICANT'S SIGNATURE X 3 �” <br /> FOR 6E0AgTMEN7`USE ONLY <br /> Feels D] e: 0 ANNUALLY ❑ PER UNIT WP ER SITE .-.– J`'o(c 1&Received By January 31 U July I Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE E)ZPLANATiON DATE DATE. -REWTTEO AMOUNT DUE CHECKED <br /> FEE - <br /> PRORATION . <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7 t'�1 'R. a -7 <br /> '' Received by Date Receipt No. P,argnit No. _ issuance Date Mailed D ere <br /> —APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PER 16ot E.HAZELTON AVE.,P.O.Box 2009 STOC ON,CA95201 �^ <br /> 1 "p� J <br />. n <br />