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JhyOvf LneO f4ilh—SlUtl4t n,CA <br /> Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION ZO - --p <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTACL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> n Business Name (DBA) �• D•A- [r��1�t r Address 3Z3 D 6 cr�R-�5�e'R AUG <br /> Owner FASa'tfs ty Address 1 is 7> 64W4EA "&4[> *PLA�Cli_r -- <br /> Firm Partners, Addresses and Telephone Numbers W.LF_(NF&L-D&4z— <br /> iBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) 444V FG_--kUMC4+ Title _f&4,4� 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. CAL.License 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. O RCOLATION TEST ,h.r <br /> R.S.or R.C.E.Name .4TrL IC.K— C- `DT�t—I— R.S. or R.C.E.No. �vv <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner 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 <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 /> 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 and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,31 ru s and ogulptions of he an 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 8 Received By January 31 ❑ July i A Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE E%PLANATION GATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE s� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br />