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` /1MFI11\.OUVIID rna oc r1�racu rr-11c11 0uu1111ucu r1VNc11y a..u111N1arcu. oe 0k. V 01911 111e MNN11cnuu11. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> r Applicatioyrwip hereby made o carr gn business in the jurisdictional area of the San Joaquin Local Health District / <br /> Business Name (DBA) / 0 L1 u eJ1 i J.,¢ ,Sp )C'.' c 4 Address <br /> Owner_e(/o xl Address LSA i_3 42�i /LNot <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. O 7 /75.Jr Emergency Telephone No. E7,V-21 6, .� <br /> Contractor Licence No. <br /> vALApplicants Name (Print) Title �, /Q�eS- Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q) <br /> ` For July 1, June 30, 19 Disposal Sites r <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. Licznse Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> r. 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 PERMIT _ // <br /> Job Address/Location�e�0 7 .C' �l�v ry � /a v '4 St?AAQ.J U S <br /> Owner J�h� ar3W pe, t Address <br /> V1 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PA KAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY Qr NEW ❑ REPAIR ❑ OTHER <br /> a. 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s)_ F <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 C <br /> o. 7. ❑ LAUNDRY For July 1,-June 30, 19 e <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,a rules and re lation of the n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> ar <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS l� ` <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER n <br /> Mailed Deliv ed <br /> Received by Date Receipt No. Permit No. Issuance Date I <br />