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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The_Application. <br /> APPLICATION <br /> ; r Non-Transferable, Revocable,and Suspends_ <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby ma a to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DSA) <br /> A.�.r-onry son. Addressyo� X /Io /'9ao%s?s Cry <br />` , - <br /> e Owner P e , Address <br /> t <br /> Firm Partners. Addresses and Telephone Numbers <br /> � <br /> i Business Telephone No. S 3V.2 �" <br /> Emergency Telephone No. <br /> -1 Contractor Licence No. 49 6 _ s�b <br /> _ Applicants Name (Print) r H� �o� Title �w�y t? �' Date C ��' �" y <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> s <br /> For July 1, June 30, 19 Disposal Sites <br /> a. <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Llccnse Rene I ? <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> r <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. Cl PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time It <br /> 4. �X.SANITAT.IflN PERM1T f, <br /> Job Address±Location 3S 't '7A-T�C'�'Saly rsSS R� �Y C Gam ' <br /> Owner 7W C- GCaU41jYy Address `- �C <br /> 'a-SEF!--IC-TANK-0, CESSPOOLLEACHING'FIELD­) ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> [i'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: El 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,and rules a egulation of the San Joaquin.Local Health District. <br /> APPLICANTS SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑.January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> 11 REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE' CHECKED <br /> DATE. A REMITTED AMOUNT <br /> 13 <br /> t FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -7 -711 -7 C7ag i 7 A,V. <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Deliv ed <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1661 E.HAZELTON AVE..P.O.BOK 2009 STO TON,CA 95291 <br /> i <br />