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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 111wor Non-Transferable, Revocable,and SuspendaBwr/ <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicat`on is hereby made to carryon busines the j ns Ictional area of th San oaquin Local ealth District <br /> F Business Name (DBA) L (- >=. W A_�'��A`�. ]' `% Address <br /> i Owner �� )V I A�T h P,I Address 45 0 <br /> Firm Partners, Addresses an CTgle hone Numbers <br /> a. Business Telephone No. Op ., <br /> a - Emergency Telephone No. C� <br /> d Contractor Licence No. (� <br /> a <br /> Applicants Name (Print) �,E ���'s H I„h Title Date <br /> Please check Applicable Category (1-7) and FIII In the Required InformnUon <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse 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. ❑ SANITATION PERO <br /> Job Addr ss/Location TL. —o�q ^1 <br /> OwnerPIN 1,S Address ` 1 0 <br /> 101 SEPT IC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT b PACKAGE PLANT <br /> ❑ 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(p) <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/Amount/Mo. <br /> I hereby certitythat I have prepared this applic ion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state Milk. and rules reg lati s the S JocutLocal Health District. - <br /> APPLICANT'S SIGNAT <br /> L o <br /> FOR DEPARTMENT USE ONLVb <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT yu PER SITE ❑ EACH ❑ Jan ry 1 8 RaceivedBy Jenuary 31 ❑ July 1 A Received By July 31 <br /> BILLING MITTA $ REMIT <br /> BASE EXPLANATION DATE DA Pyt REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> ( AMOUNT <br /> ys L <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> b sJa� l�� 3 h 6s9�c� <br /> Received by ate Receipt No. Permit No. lasuance Date MaifeO Da I era <br /> 67 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCK N,CA 201 <br /> r7 <br />