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APPLICATION <br /> 14r 4� i Y <br /> F1 <br /> (I '+ion-'transferable,Revocable, and Suspendable' <br /> cNVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE 4 <br /> Application is er y made to carry o usiness in the jurisdictional area of the San Joaquin Local Health.District <br /> F,,siness Name (DB ) L� Address e- <br /> Owner � JI-:,ZrLc=��. Address-- � f 1 ,� iP L } 17�rl — <br /> rm Partners, Addresses and Telephone Numbers <br /> usiness Telephone No. a✓ _.. Emergency Telephone No. <br /> .,ontractor Licence No. .r <br /> Applicants Name (Print) 15, Title Date 4' 9-'Z> <br /> Ftaseecheck Applicable Category(1-7)and Fillin the Required Information <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> escription(Make/Yr., Color) <br /> eHal No. CAL. License No. CAL. Licc ,se Renewal No. <br /> t . <br /> Capacity Gal.,Weights&Measures No. <br /> quipment Parking Address <br /> ❑ PUMPER YARD <br /> or July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> Fo. of Chemical Toilets Stored <br /> ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or.R.C,E.No. r� <br /> est Location Test Date/Time ~ <br /> I ❑'SANITATION PERMIT <br /> i <br /> .,ob Address/Location 10 74 -k! Ke_ <br /> Owner �� �/i2/, l_fa- Address 3 <br /> PSEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑,�, SV AGE PIT- ❑ PACKAGE PLANT <br /> i PERMANENT 11 TEMPORARY ❑ NEW Z' EPAIR ❑ OTHER al.S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> type <br /> Construction Disposal Site <br /> o. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> dlperator Name Where Certified <br /> ant Location <br /> ant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> FIZE: © Less Than 1,000 Sq. Ft., . 11 More Than 1,000 Sq. Ft. <br /> 1 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 and regulations of the San Joaquin Local Health District. <br /> F <br /> ,PPLICANT'S 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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> �} DATE DATE REMITTED AMOUNT <br /> FEE 1;{ <br /> LESS <br /> PRORATION <br /> PLUS <br /> t <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 Received by Date Receipt N. - Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON.AVE.,P.O.Box 2009 AASTOCKTON.CA 05201 <br />