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Applications Will be Processed When Submitted Properly Completed. Be Sure Toi The Application. <br /> n APPLICATION <br /> (For Nuri=Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is ereby made to arty on busi ess in the j di Tonal area of the San Joaquin Local Health District <br /> iness Name (OB r G � -C4 ��, -7 I <br /> Address <br />'ler +{ Address <br /> i Partners, Addresses and Telephone Numbers <br />'mess Telephone No. _ � f dS _.. Emergency Telephone No. <br /> tractor Licence No. 2 <br /> licants Name (Print) c" Title �J DateGr <br /> Ise check Applicable Category (1-7) and Fill in the R uired Information <br /> 3 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> July 1, June 30, 19 Disposal Sites <br />-ription(Make/Yr., Color) <br /> al No, CAL. License No. CAL. License Renewal No. <br /> acity Gal., Weights & Measures No. <br /> ipment Parking Address <br /> 71 PUMPER YARD <br /> July 1, June 30, 19 <br /> of Vehicles Stored <br /> of Chemical Toilets Stored <br /> PERCOLATION TEST <br /> or R.C.E. Name R.S. or R.C.E. No. <br /> L ation Test Date/Time <br /> SANITATION PERMIT <br /> Add /L ion <br /> er �L�P � � _ Address - <br />;EPTIC TANK El CESSPOOL�EACHING FIELD SEEPAGE PIT �102P �XCG PLANT <br />'ERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> CHEMICAL TOILETS For July 1, -June 30, 19 4-1 <br /> Construction Disposal Site <br /> o� <br />:)f Units Equipment Storage/Cleaning Location(s) <br /> I PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br />-ator Name Where Certified <br /> I Location <br /> Capacity No. Units Served <br /> LAUNDRY For July 1, -June 30, 19 <br /> ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft, <br /> RY 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, and rule nd regulat.iiionnss of t San Joaquin Local Health District, <br /> JCANT'S SIGNATURE T FOR DEPARTMENT DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 0 January 1 &Received By January 31 ❑ July 1 a Received By July 31 <br /> BASE EXPLANATION BELLING REMITTANCE $ REMIT \ <br /> DATE DATE REMITTED AMOUNT DUE CHECKED R� <br /> AMOUNT 'J[` <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> r <br /> f 3 a (o <br /> Received by Date Receipt No. Permit No. 4uance Dae Mailed Delivered <br />— APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.ao>t 2009 ISTOCi(TON+CA 95201 <br />