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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i hereby made to carry on b slness int pe jurisdictional area of the San Joaquin Local Health Di ict <br /> iaBusiness Name BA) '� Address AP�v 7,1 <br /> i Owner - Address -�'"- -- <br /> 4 sses <br /> Firm Partners, Addreand Telephone Numb rs <br /> aBusiness Telephone I ��� .r�d.f Emergency Telephone No. <br /> 11 Contractor Licence No. z— J6o <br /> L Applicants Name (Print) ArS �'' - Title Date Z--- 7V <br /> Please cheek Applicable Category(1-7) and Fill in the Required Information NN <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites - `I <br /> Description(Make/Yr.,Color) U <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. _ <br /> Capacity Gat..Weights& Measures No. - � <br /> Equipment Parking Address — <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 J` <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 Lotion Test Date/Time <br /> 4. lD SANITATION PERMIT a-f <br /> Job Address/Location 1"- <br /> Ow r Q'�+'+t-d�c� i/�.c.�- Ad ress <br /> �,J�EPTIC TANK ❑ CESSPOOL ACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> I�PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ 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: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMo. <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 r Ois and regulation t e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <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 /> BASEE%PLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> C/ DATE DATE REMITTED ./ AMOUNT <br /> FEE �✓ �7 <br /> LESS <br /> PRORATION -- <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a�3se 9 � <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed rve <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Dos 2009 STOC O ,C 95201 <br /> _r' - , i - / /i1 i .tea. - O J- 1 !1- i <br />