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� APPLICATION <br /> (FL on-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGh <br /> LIQUID WASTE <br /> Applicati is hereby made to carry on business in t e jurisdictional area of the San Jo quin Local HeajAi District <br /> Business Nam (DBA) 4E" / OeAddress d9e ,-1-7-7 <br /> Owner' L Kr_-* X,_ Address O /-_I� Ze <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. 40- ` C Emergency Telephone No. <br /> Contractor Licence No. 2�` Z <br /> Applicants Name (Print) ENCS 7r t) gC�1 Title. Date -7 <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) I _ t <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. V <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 /> ❑ SANITATION PERMIT 3 <br /> J � ��� <br /> ob Address/Location r 1] <br /> Owner ,&, Address 8#j—e )v Jy-ld S c 5752 3 7 <br /> SEPTIC TANK ❑ CESSPOOL ,�'EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT 11 TEMPORARY L� 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: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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 rul h and regulations o the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X zt <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 18 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> /1 <br /> FEE '7s r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ?q--7 0-3 <br /> Received by Date Receipt No. Permit No. Isjuancla Date Mailed Ddliverely <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.14AZELTON AVE.,P.O.Bo:2009 STOCKY N,CA 85201 7 <br />