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APPLICATION , <br /> ( ,,Aon-Transferable, Revocable,and Suspendablej„.o <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> I Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> -L"usiness Name (DBA) P,04 �`'���� �o.t/�.-�it.0 — Address 'S7. <br /> s <br /> Owner Address <br /> irm Partners, Addresses and Telephone Numbers <br /> mousiness Telephone No. �ZA06` 91607 Emergency Telephone No. <br /> Contractor Licence No. -- <br /> �, pplicants Name (Print) r gvj Title `��. Date ��_ <br /> Lti <br /> tease check Applicable Category(1-7) and Fill in the Required Information <br /> 4. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> )escription(Make/Yr., Color) <br /> Luerial No. CAL. License No. CAL. Licc7ise Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> :quipment Parking Address <br /> LW. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> Jo. of Chemical Toilets Stored <br /> L'3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. <br /> est Lo ton Test Date/Time <br /> SANITATION PERMIT 1 <br /> Job Address/Locations <br /> awn �� I Addr ss /0A a� S � �� e,4. w1 <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT El PACKAGE PLANT 1� <br /> ERMANENT ❑ TEMPORARY ONEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ! <br /> Type Construction Disposal Site <br /> U,Vo. of Units Equipment Storage/Cleaning Location(s) 9C <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> .7perator Name Where Certified r <br /> ...?lant 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.r <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,. nd rules a regula i s of a an Joaquin Local Health District. <br /> L-APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT Jag PER SITE ❑ EACH - ❑ January 1 &Received By January 31 ❑ Ju4y 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> i.r DATE DATE REMITTED CC AMOUNT <br /> FEELy <br /> LESS <br /> .0 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> } OTHER <br /> OTHER <br /> ` Received by Date Receipt No. Permit No. I Issua4ice Date Mailed Deli red <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,-P.O.Box 2009 ST KTON, A 95201 <br />