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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION „ v - Z (7 (D <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE r <br /> LIQUID WASTE G <br /> Application I -py-r'ade to car on business in the jurisdictional area of the San Joaquin oval Health District <br /> rBusiness Name (DB ) 7'r'aT e "Rd ei 546&01 Ce ---Address D ix7 r <br /> z Owner E� Address oS 5' F41015;eT <br /> a <br /> u Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. aha Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) /o'�l� �� `��T - Title Date lw —1-f-77 <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. License 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. i <br /> Test Location Test Date/Time <br /> 4. 1:1 SANITATION PERMIT <br /> Job Addre /Location (� <br /> Owner ¢ S Address �5If P 6R 6/f 17, <br /> ❑ SEPTIC TANK ❑ CESSPOOL Pr LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER 4Q <br /> 5. ❑ CHEMICAL TOILETS r For July 1, -June 30, 19 t ) <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) 1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name 3 Where Certified <br /> Plant Location <br /> Plant Capacity I -� I No. Units Served <br /> 7. ❑ LAUNDRY For.July 1, -June 30,.19 -+ <br /> SIZE: ❑ Less Than 11,000 Sq. Ft., d ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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, r es and regulati ns of the an Joaquin Local Health District. <br /> t 31 y` <br /> APPLICANT'S SIGNATURE X <br /> � r <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 /> _ BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED a AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> c�3.537 <br /> --Received by- -- -- Date Receipt No. Permit No. Issuance Date IDefive <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL PERMIT/SERVICES �11 E.- LTON AVE.,P.O. 9� CKTON,C 95201 <br />