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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 is Liereebby made to carry on busines in the jurisdictional area of theSanJoa uin Local Health District L <br /> F Business Name(DBA) N �. JdMstpdCN� �Y Address / oX /.� T c7i'/✓T'o ✓ C'A <br /> aOwner 6A N/ k Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 79�I- 3 3& Emergency Telephone No. <br /> j Contractor Licence No. O <br /> L Applicants Name (Print)—, _Title O N/,I��' 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 1 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc;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 /> gSANITATION PERMIT <br /> Job Address/Locatn x//-� //U�'z_ /W <br /> Owner_41LXA-1 <br /> �C�j>�r Address T, O &o.sl /.-9 Fr 7/✓a,!PA/ToA/ r"51195 i.P <br /> M SEPTIC TANK 13CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ 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 r <br /> SIZE: 11 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 t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rulpia arW regulations the J aquin Local Health District. I�[1 <br /> APPLICANT'S SIGNATURE X (� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE j REMIT <br /> BASE EXPLANATION DATE DATE REMITTED /+MOUNT DUE CHECKED <br /> E(J! AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS Nn- \ <br /> PENALTY <br /> OTHER `() <br /> OTHER <br /> D 2 v�3 d $ 3q � ld <br /> Received by ate Recelpl No. Permit No. Issuance bar <br /> eDelivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AV .BMalletlev dare CrnC¢rnN <br />