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APPLICATION <br /> Non-Transferable, Revocable, and Suspendabl <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati nnhher by made to carry bu In ss in the�urisdictional area of the San Joaquin Local Health District <br /> r Business Name (DBA) r'1 KCi C'S ��� �� Address f�� <br /> a Owner /?j'1 C'Fa(LC f f Address " <br /> Firm Partners, Addresses and Telephone Numbers 1 <br /> a Business Telephone No. � ___ Emergency Telephone No. (� <br /> :2y3gi 8 <br /> Contractor Licence No. ,c1 <br /> L Applicants Name (Print)_ I /m R C0A Title _ _ Date _ <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) <br /> Serial No. CAL. License No. CAL. Lice;se 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 PER _ / A� ' Q <br /> Job Address/Location ` L ' -v y I_�� __ y�C+ <br /> Owner &E E. G fire:t_ Address /O 3 01-) /.=" /-/W y /!2 Q /jlr :lcrv�i O <br /> ❑ SEPTIC TANK ❑ CESSPOOL R LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ® REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _ L <br /> Type Construction_ Disposal Site AOa J` ' __X /y`_ iC IC�� �S' <br /> No. of Units — Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 O <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 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 Joaq Local Health District. <br /> APPLICANT'S SIGNATURE X / LHS �� ��I/ ` — <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -7110130 3-7LS --0 (,0YS— I ) �0 <br /> Received by Date Receipt No. Permit No. Isce Date Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC TON, k201 <br />