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rr <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ` (. �. or Non-Transferable, Revocable, and Suspendabier <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> y LIQUID WASTE <br /> Appi,calionere made c ry on ysmess iri the jurisdictional area of the Sa J^a^uin L ca!Health Dist/'^ct <br /> Business Name (DBA)_ ._ ' !f1 N 5 <br /> 1AddressyP/�L1 r�1/4!� <br /> Addr19� C <br /> 7wnerC Q <br /> _ <br /> Address <br /> .I11�Irm Partners, Addresses and T Iephone umberss <br /> i 9usiness Telephone No. 3 0 { Emergency Telephone No. <br /> Contractor Licence No. 27 XX 3 oto pplicants Name (Print) v C Nr� Title �47Ae/L Date <br /> ease check Applicable Category (1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> or July 1, June 30, 19 _ Disposal Sites <br /> `escription(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Llcc.se Renewal No. <br /> apacity Gal., Weights & Measures No. <br /> .quipment Parking Address <br /> 2. ❑ PUMPER YARD 1 <br /> °or July 1, June 30. 19 <br /> io. of Vehicles Stored <br /> 'Mo. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST _ <br /> .S. or R.C.E. Name R.S. or R.C.E. No. <br /> nest ocation Test Date/Time <br /> 4. L SANITATION PERMI CJD0 /�� (� �7�' - <br /> ob/Address/Location s y�I 1 k 10A) l�(4. F_IM h'1 1 tv /p /V 1 <br /> ner /a A c_ o 1.4.01 Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARYp�"('NEW 11 REPAIR C1 OTHER <br /> ❑ CHEMICAL TOILETS For July 1, -June 30, 19 j <br /> "rype Construction Disposal Site + <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> wperator Name Where Certified <br /> Plant Location <br /> [ant Capacity _ No. Units Served <br /> r ❑ LAUNDRY For July 1, - June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> rl DRY CLEANING, Chemicals Used/AmounUMO. <br /> I hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a d .I and regulations f the San Local Health District. <br /> "PPLICANT'S SIGNATURE _ (�/iyA � <br /> V <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PEP SITE ❑ EACH ❑ January 1 d Received By Jarwary 31 ❑ July 1 &Received By July 31 <br /> - -. T — -- REMIT <br /> BASE E%PLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 7 1EE <br /> LESS 7 <br /> PRORATION_________ _ <br /> PLUS — — <br /> PENALTY <br /> OTHER I I_.. _ —__. I --T <br />