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Applications Will Be Pr, 'seed When Submitted Properly Completed. Be F To Sign The Application. <br /> ..c APPLICATION �-- <br /> - (For Non-Transferable,Revocable,and Suspendable) - <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry onbusiness in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name DBA) ' •r Address es +S'�• 0" t , P <br /> Owner Address 14nde.—' <br /> Firm Partners. Addresses and Tele one Numbers <br /> a Business Telephone No. —y Emergency Telephone No. <br /> Contractor Licence No. -1 <br /> L Applicants Name (Print) � { !�-�rP `�P s Title -l�Ar���!'7�2✓X Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Cn 'k;i5 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) I� <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 <br /> 4. XSANITATION PERMIT / dr C] <br /> Job Address/Location a-{/C..s.- <br /> Owner A dress�ss/ X <br /> PSEPTIC TANK 11 CESSPOOL A <br /> LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT _- <br /> XPERMANENT ❑ TEMPORARY XNEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 .1 <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 —1 <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, stale laws. <br /> /.a.Arul and regulations oofftth,S San Joa Lin Local Health District. <br /> APPLICANT'SSIGNATUREX 6 �1CL-d'� 6'� .��AE',Gr='S SEMC & SEY•iER SERVICE <br /> 7.C3 Sa. 0.0 -v. SrccLton, C..T. 95205 <br /> ?it S' ., ?9 Contr2r.;et'a iic -2ii7177i <br /> i <br /> 1�` FOR DEPARTMENT USE ONLY \� <br /> Fee Is Due: 11y?ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Rech/;&"9Y January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE EMITTED AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received Dyy ata Receipt No.. Parmil No. Issuance Date Mailed Delivare0 <br /> 1PC11/`1YT�PRIIPH 111 Cl1P1FR Tb. LNVIRO..FNT.1 HFC.TH PFRMITISFRVH:Es tRat F HAZELTON AVE..P.O.B.2009 STOCKT N.CA 25201 <br />