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APPLICATION <br /> INon-Transferable, Revocable,and Suspendal <br /> ENVIRONMENTAL HEALTH PERMIT' SEPTAGE t- <br /> LIQUID WASTE <br /> Application is hereby made/to carry on business in the jurisdictional area of the San Joaquin Local Health District . <br /> wBusiness Name (DBA) z1,PA Address 1rl�-12" <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. <br /> :Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) _ TitleDate <br /> Please check Appllcabte 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 w <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. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location' Test Date/Time LA <br /> I <br /> 4. 0 SANITATION PERMIT � <br /> Job Address/Location 2�fir • T SSC-rte .¢J [� <br /> Owner A.OS Al Address s7: /x -F- <br /> 11 <br /> F—❑ SEPTIC TANK ❑ CESSPOOL ""' ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PL NT _ <br /> ❑ PERMANENT ❑ TEMPORARY ❑.NEW ❑ REPAIR OOTHER �77 <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> 1_V <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 /> ❑ Di �d i l j ,mount/Mo <br /> - t1Sf},r1�RJ1134''3`�t0`i P,C$itt¢"�fftl( fa4 -�tbn,FCrferiltanGeofthe viorkfor,vrhicttthis eermitisii;3ued,l,shaftnotem lo' 8 <br /> �;�-��►tr�s"s�. �' P r! m+Person <br /> y p13,sPs:S a"je;,t 4.)worholiws 4 :` ;7 a °;lot 11g: "i certify that in the performance C°9x viork for tvflic thfs pert itis issued,I shall <br /> ,. , ....a s <br /> I hereby certify that I have prepared this applicatiori and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of San Joaquin Local Health District. -v <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USt ONLY 61 <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> -BILLING REMITTANCE $ REMIT _ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> 1 AMOUNT <br /> FEE �/ �l <br /> LESS . <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> Received by Date Receipt No. Permit No. tssuan a Date Mailed Delivered <br /> APPLICANT'—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE P.O.Box 2009STO'6' N,CA 95261 <br />