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... .. APPLICATIONn. ~ <br /> Non-Transferable, Revocable,and Suspendabi <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGF <br /> LIQUID WASTE <br /> ApplicatLo is here ade to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) �/a 8p S'�j �/�� <br /> a Owner �r�c Address d S: S .a j" a <br /> Address <br /> j.Firm Partners, Addresses and Telephone Numbers <br /> QBusiness Telephone No. 1 � 1 <br /> -j.Contractor Licence No. Emergency Telephone No, <br /> L Applicants Name(Print) e <br /> Please check Applicable Category(1-7)and Fill In the Requited Information Title Date <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 <br /> Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAI. License No. <br /> Capacity CAL, License Renewal No. <br /> 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 <br /> R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. 11 SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address v!—.�L <br /> ❑ SEPTIC TANK CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 13 NEW REPAIR OTHER ,S'6�/72P <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site 1 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Plant Location <br /> Where Certified <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 havepreparedthis application-and that the work will be done in accordance wit J in ounty <br /> ordinances,state lava r s and regulations of the Sa oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> co <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 /> BASE EXPLANATION BILLING REMITTANCE S REMIT <br /> DATE DATE REMITTED AMOUNT DUE, CHECKED <br /> FEE ,q AMOUNT <br /> LESS �P <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date RBCeipt No. permittln W <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. I ua ate Mailed elive - <br /> 1601'E:HAZELTON AVE.;P.O.Bvk2009.. STO TON,C 95201 - <br />